JOHN P. FULTON, PHD, HENRY C. BODENHEIMER, JR., MD, AND PETER D. KRAMER, MD. Abstract: We reported earlier on 1,500 hospital employees.
Acceptance of Hepatitis B Vaccine among Hospital Workers: A Follow-up JOHN P. FULTON, PHD, HENRY C. BODENHEIMER, JR., MD, AND PETER D. KRAMER, MD receive vaccine, either because they had left the hospital, or because tests revealed that they had been exposed to hepaAbstract: We reported earlier on 1,500 hospital employees titis B. Of the 199 remaining subjects, about half attended whose desire for hepatitis B vaccine was assessed. We followed 229 hepatitis B seminars, and half did not. We recorded whether of these subjects to measure the effect of a voluntary educational or not respondents received vaccine. intervention on desire for vaccine. Acceptance of vaccine declined The questionnaire used for the reinterview was almost in 37 per cent of subjects and increased in 13 per cent. One of the identical to the questionnaire used for the initial interview. ' extraneous influences on demand for vaccine may have been highIt contained questions to measure knowledge, health beliefs, profile media coverage of the AIDS (acquired immune deficiency syndrome) epidemic. (Am J Public Health 1986; 76:1339-1340.)
Introduction We reported previously' on a survey of 1,500 hospital employees which assessed the demand for hepatitis B vaccine. Twenty per cent of the variance in respondents' desire to receive vaccine could be explained; among measured determinants of demand, health beliefs about the safety and efficacy of the vaccine influenced acceptance most. When the survey was completed, the hospital began a hepatitis B vaccination program for employees who were judged to be at increased risk of contracting the disease. "Hard sell" was avoided,2 and eligible employees were invited to small seminars on the prevention of hepatitis B, and offered vaccine at no cost. Employees who elected to be vaccinated signed a consent form. The program was run by a small team which visited eligible departments over nine months. During team visits, all employees were invited to attend a seminar which included a film on hepatitis B and hepatitis B vaccine, followed by discussion. The film, produced by Merck Sharp & Dohme, illustrated different routes of infection and courses of illness. It described the vaccine, including known side effects, but did not emphasize its positive attributes or its safety. Following the session, employees who wished could sign up to be vaccinated. The vaccination program was undertaken at a time when acquired immune deficiency syndrome (AIDS) had received much media coverage, but before the virus responsible for AIDS had been identified.3'4 Data demonstrating the lack of HTLV-III antibodies in vaccine recipients5 as well as the conclusive inactivation of retro viruses in vaccine preparation5 were not yet available, nor were longer-term safety data.6 We studied the effects of the hospital's vaccination program by reinterviewing a subsample of employees after they had had the opportunity to participate in the educational program.
Methods We chose a random sample of 249 initial respondents, stratified by risk group. Of these, we successfully reinterviewed 229. Subsequently, 30 of the 229 became ineligible to Address reprint requests to John P. Fulton, PhD, Department of Community Health, Box G, Brown University, Providence, RI 02912. Dr. Bodenheimer is with the Department of Medicine, RI Hospital and Brown University; Dr. Kramer is with the Department of Psychiatry, RI Hospital. This paper, submitted to the Journal March 31, 1986, was revised and accepted for publication April 23, 1986.
©1986 American Journal of Public Health 0090-0036/86$1.50 AJPH November 1986, Vol. 76, No. 11
and inclination to accept vaccine. Answers to individual survey questions were combined to form one knowledge scale and three health belief scales: "susceptibility to hepatitis B," "severity of hepatitis B," and "safety and effectiveness of hepatitis B vaccine." Coefficient alpha was computed as a measure of reliability for each of the four scales: susceptibility, 0.49; severity, 0.77; safety and effectiveness, 0.69; knowledge, 0.52. The values for susceptibility and knowledge indicated that the statistical effect of the two scales might be attenuated by random error. We accounted for this in our interpretation of statistical results. We used interview responses to answer three questions: * Were respondents who attended seminars different from those who did not? Log-linear analysis was used to answer this question. * Did the seminars promote vaccine acceptance? Multiple analysis of variance was used to answer this question. * Did employees change their minds about accepting vaccine between the two interviews, and to what extent was expressed desire to accept vaccine related to receiving the first injection? Crosstabulations were used to answer this question.
Results
Employees at highest risk of contracting hepatitis B were more likely than others to have attended the seminars. Knowledge, health beliefs, and propensity to accept vaccine (measured in the first interview) had no noticeable effect on attendance (data available on request to author). Controlling for risk group and elapsed time, attendance at seminars had little effect on knowledge, health beliefs, or propensity to accept vaccine. The seminars did increase the perceived severity of hepatitis B among attendees (data available on request to author), but had no effect on beliefs about vaccine safety and effectiveness. Multiple analysis of variance (controlling for risk group, knowledge, and other health beliefs), revealed that respondents felt less susceptible to hepatitis B over time and reported less likelihood of accepting vaccine. About half the respondents had changed their minds about accepting or rejecting vaccine between interviews (Table 1). Thirty-seven per cent reported less likelihood of receiving vaccine, and 13 per cent reported greater likelihood of receiving vaccine. Reported likelihood of accepting vaccine at the time of the second interview was a good predictor of vaccination (Table 1). Of 70 respondents who reported wanting the vaccine at the time of the second interview, 61 per cent received the first injection. Of 94 who reported not wanting the vaccine, 4 per cent received the first injection. Of 18 who were unsure, 11 per cent received the first injection. 1339
PUBLIC HEALTH BRIEFS TABLE 1-Reported Acceptance of Hepatitis B Vaccine after Seminar by Reported Acceptance of Hepatitis B Vaccine before Seminar; Actual Vaccination after Seminar by Acceptance of Hepatitis B Vaccine after Seminar Reported Acceptance Before Seminar
Reported Acceptance After Seminar Want
Undecided Don't Want Total
Want
Undecided
Don't Want
Total
53 6 39 98
13 5 22 40
4 7
70 18 94 182
33 44
vaccine, perhaps because accurate and up-to-date information about hepatitis B vaccine safety has indicated consistent safety in long-term follow-up studies.5'6 In spite of the unforeseen influence of external events, our data suggest that the educational component of a hepatitis B vaccination program may be most likely to increase acceptance if targeted to employee health beliefs about vaccine safety and effectiveness. ACKNOWLEDGMENTS A portion of this research was supported by a grant from Merck Sharp & Dohme, West Point, PA; an abstract of this research was published in Clinical Research 1985; 33:251A.
Reported Acceptance After Seminar Actual Acceptance Accepted Did Not Accept Total
Want
Undecided
Don't Want
Total
43 27 70
2 16 18
4 90 94
49 133 182
Discussion
The strength of the decline in vaccine acceptance suggests a strong extraneous influence unrelated to measured health beliefs. Fear that AIDS had compromised the safety of the vaccine7 may have been an important factor. Since the time of the second interview, we have observed some dissipation of the early reluctance to accept
Tufts Environmental
REFERENCES 1. Bodenheimer HC Jr, Fulton JP, Kramer PD: Acceptance of hepatitis B vaccine among hospital workers. Am J Public Health 1986; 76:252-255. 2. Baker CH, Brennan JM: Keeping health care workers healthy: Legal aspects of hepatitis B immunization programs. N Engl J Med 1984; 311:684-688. 3. Popovic M, Sarngadharan MG, Read E, Gallo RC: Detection, isolation, and continuous production of cytopathic retroviruses (HTLV-III) from patients with AIDS and pre-AIDS. Science 1984; 224:497-500. 4. Gallo RC, Salahuddin SZ, Popovic M, Shearer GM, Kaplan M, Haynes BF, Palker TJ, Redfield R, Oleske T, Safai B, White G, Foster P, Markham PD: Frequent detection and isolation of cytopathic retroviruses (HTLV-III) from patients with AIDS and at risk for AIDS. Science 1984; 224:500-503. 5. Centers for Disease Control: Hepatitis B vaccine: evidence confirming lack of AIDS transmission. MMWR 1984; 33:685-687. 6. Centers for Disease Control: Recommendations for protection against viral hepatitis. MMWR 1985; 34:313-335. 7. Anderson AC, Hodges GR: Acceptance of hepatitis B vaccine among high-risk health care workers. Am J Infect Control 1983; 11:207-211.
Management Center Receives $2.4 Million Grant
The Tufts University Center for Environmental Management has received $2.4 million from the United States Congress to study the effects of hazardous waste on health and the environment. The grant will be administered by the US Environmental Protection Agency. The center, which had previously received more than $3 million in federal aid since it opened in 1984, sponsors research and organizes conferences on waste treatment policy and technology, groundwater contamination, and health effects of chemical exposure, among other things. The new grant will support research by center staff members and Tufts faculty members on the university's Medfor, Boston, and Grafton campuses. Interdisciplinary research is being emphasized and the research projects will bring together medical specialists, engineers, scientists and policy analysts to address complex environmental problems. Of particular interest is the center's work on health issues, where it is assessing the effectiveness of various new tests of chemical toxicity in humans. This fall, the center will conduct the country's first national conference on household hazardous waste, to be held in Washington, DC, in cooperation with the EPA. The center also will cosponsor an international environmental conference with the Sierra Club in 1987. The center, which is supported by industry as well as the federal government, is directed by Anthony D. Cortese.
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