Abstract
While vaccination is the only established option to prevent a susceptible host from influenza, we have yet to clarify the decision-making mechanisms of vaccine uptake among Japanese university and college students. We aimed to explore vaccination coverage and the related demographic, sociocultural, and socioeconomic factors among university students. We performed a cross-sectional survey involving 604 students at Hokkaido University. Participants were asked if they received influenza vaccination in advance of the 2018/19 season, and subsequently, their demographic and sociocultural/socioeconomic characteristics were surveyed. We also explored the mechanisms underlying students’ vaccination decisions. Vaccination coverage was estimated at 27.3% (95% confidence interval: 23.7–30.9). Freshmen (p < 0.0001) were significantly associated with choosing vaccination, and their odds ratio of vaccination was 11.3 (95% confidence interval: 6.2–20.7) times greater than students in other years. Among students other than freshmen, students belonging to medicine- and healthcare-related faculties were vaccinated three times more frequently than other students, and the coverage in students from Hokkaido was twice as large as that for students from other prefectures. Moreover, extracurricular activity was a positive predictor of vaccination. Although the coverage was as small as 27.3% among university students, freshmen in Japan have high vaccination coverage, which we believe is associated with the entrance examination during high influenza activity. In addition to exposing students to proper education regarding their risk self-assessment, consciousness raising via appropriate understanding of influenza and its severity and offering vaccination at university health centers at a reasonable cost may promote vaccine acceptance.
Keywords: immunization, prevention, epidemiology, students, vaccination effectiveness
1. Introduction
Influenza is a viral infectious disease caused by the influenza virus, an RNA virus that belongs to the family Orthomyxoviridae [1]. Seasonal influenza epidemics occur in winter to early spring. Influenza is distinguished from the common cold by a fever of >38.0 °C that is frequently accompanied by upper respiratory symptoms of sore throat, cough, and nasal discharge, and also by chills, headache, and muscular and joint pain [2]. Annually, influenza is responsible for approximately 291,000–646,000 deaths worldwide [3,4], and the social and economic impact includes not only absenteeism and the need to seek medical attention, but also restricted range of movement during the symptomatic period and loss of work [5,6,7].
Vaccination is the only established option to prevent a susceptible host from contracting influenza infection and developing its severe complications [8,9]. Immunization offers direct protection in vaccinated individuals as well as “herd immunity” to the population via indirect reduction in the opportunities for infection [10,11,12,13,14,15]. In many countries, influenza vaccination is part of a national immunization program, and Japan is no exception. However, the routine immunization program in Japan, which rests on Immunization Law and is conducted by local government, covers only older people with underlying comorbidities such as chronic obstructive pulmonary disease and chronic renal failure, and vaccination in other age groups, including children, is voluntary.
University and college students in Japan are known as not achieving high vaccination coverage, which is estimated at 20%–30% [16,17,18,19], and coverage surveys have indicated that younger school children and older adults achieve higher coverage at a rate of 50% for each group [20,21,22,23], which is not substantial enough to establish herd immunity [24]. Influenza among university and college students results in absenteeism of at least 5 days because of the time from illness onset and at least 2 days required to recover from pyrexia. Moreover, the total cost required for the medical services (i.e., physical examination, rapid diagnostic testing using nasopharyngeal samples, and prescription of antivirals) for a single student is 10,000 Japanese Yen (equivalent to 90 US dollars as of November 2019) [25,26,27]. Considering that students belong to various communities and are highly mobile both domestically and internationally [10,13,16,23,27], their vaccination is of utmost importance to prevent the spread of the disease within the community.
While the determinants of vaccination were explored among working-age people in Japan [28,29,30], studies have yet to clarify what demographic, sociocultural, and socioeconomic factors characterize university and college students’ intentions to undertake vaccination. In other countries, university and college students’ vaccination has been surveyed more closely [31,32,33,34]. For instance, in the USA, vaccination coverage among medical students appeared to be low, at approximately 40%–60% [35,36,37,38]. In other countries and levels of expertise, the coverage varies, with nursing students at 15.2% in Hong Kong [39], medical students in China at <10% [40], medical students in Australia at 30%–50% [41], and medical students in Italy at 54% [42]. To explain the variation, students’ socioeconomic class was associated with vaccine uptake [43,44,45], and students’ attitudes toward vaccination (e.g., safety concerns regarding adverse events) was shown to influence vaccination uptake among nursing and public health students [35,36,40,46]. In Japan, the decision-making mechanisms in vaccine uptake in Japanese university and college students have not been clarified, which prevents objectively designing strategies to prevent influenza via vaccination. The present study aimed to explore the vaccination coverage and its demographic, sociocultural, and socioeconomic factors among university students.
2. Materials and Methods
2.1. Cross-Sectional Survey
We performed a questionnaire-based cross-sectional survey to identify the epidemiological determinants of vaccine uptake among students to help improve vaccination programs. We conducted the survey at Hokkaido University during students’ annual health check-ups, organized by the University Health Center, in April 2019. In Japan, all university students are mandated to undertake general health check-ups according to the School Health and Safety Act. The first author performed the in-person questionnaire surveys at the health check-up zone on campus and also at the entrance to the canteen during the above-mentioned period. Before students completed the survey, the first author explained the purpose and contents of the survey, and only when students agreed to participate, were they asked to answer questions on a single sheet of paper (see Additional File 1), which required approximately 5–10 min per person. We used convenience sampling, and of the total of 11,210 students, we invited 604 students because we assumed that vaccination coverage was approximately 17% [11,12,13], and we aimed to detect any difference with a reliability of 95% and error of 3%.
2.2. Questionnaire Survey
We used a self-administered non-standardized questionnaire survey, in this study. Participants were asked if they received influenza vaccination in advance of the 2018/19 season. We recorded participants’ demographic variables, namely, sex, age, grade/year, academic major (faculty), place of birth (Hokkaido or elsewhere), and whether they engaged in extracurricular activities (e.g., sports club). To understand answering categories, Table S1 (Supplementary Material) shows the English translation of our questionnaire. Regarding the socioeconomic variables that potentially explained the mechanisms underlying the decision to receive vaccination, we asked (i) whether participants received a monthly allowance from their parents, (ii) whether participants received a scholarship, and (iii) students’ parental education levels (e.g., up to high school or university or postgraduate level). We also asked participants about the mechanisms underlying their vaccination decision; participants checked the following item if it applied: (a) worried about the risk of contracting influenza, (b) dislike injections (because of pain), (c) worried about the clinical seriousness of influenza, (d) a perception of limited vaccine effectiveness, (e) concerned with the cost of vaccination, (f) worried about having an allergic reaction to a vaccine, (g) would decide depending on the vaccination status of the surrounding people, (h) would depend on the availability of a nearby healthcare expert, (i) worried about adverse reactions following vaccination, (j) whether their general health status is good, and (k) whether students had sufficient time to undertake vaccination. The questionnaire was anonymously handled, and its electronical input was made by the first author, followed by a double-check by the second author.
2.3. Statistical Analysis
First, we examined participants’ descriptive characteristics, including their demographic and socioeconomic aspects. We estimated the overall vaccination coverage at Hokkaido University, as the main outcome. Second, we performed a univariate analysis to analyze the association between influenza vaccination and each possible explanatory variable. Because both vaccination and explanatory variables were considered dichotomous, we used the chi-square or Fisher’s exact test. We then calculated the odds ratio (OR) of vaccination for a given status of the explanatory variable. Third, cross-tabulation of vaccination coverage by two variables that were significantly associated with vaccination during univariate analysis was explored to examine possible interactions. Finally, maintaining vaccination coverage as the outcome, we investigated students’ attitudes toward influenza vaccination that could lead to a vaccination decision. Students’ attitude was considered a dichotomous outcome, and we used the chi-square or Fisher’s exact test and calculated ORs. p < 0.05 was considered statistically significant.
2.4. Ethical Concerns
Prior to the beginning of the questionnaire survey, students were informed of the study purpose, and written informed consent was obtained. The first author explained how the information would be used and assured students of the confidentiality of their responses. The research team explained that enrollment in this study was voluntary, and gave students the explicit right to withdraw at any time. When the student was younger than 20 years of age, the student’s parent or guardian was asked to sign the consent form on his/her behalf and given the chance to decline to sign the document. The Medical Ethics Committee of Hokkaido University Graduate School of Medicine (Japan) reviewed and approved this study (ID: Med19-002).
3. Results
Of the 11,266 students at Hokkaido University as of April 2019, 604 students (5.4%) responded to the questionnaire. Excluding graduate students, students from other universities, and those with difficulty reading Japanese (and not enrolled in faculty programs), data from 593 students were eligible for subsequent statistical analyses. Table 1 summarizes the distributions of the surveyed variables, namely, sex, age, and grade/year, compared with data for the entire university. Participants’ sex, grade/year, faculty, and place of birth did not differ from data for the entire population. A total of 162 students received vaccination in the 2018/19 season, and the vaccination coverage was estimated at 27.3% (95% confidence interval (CI): 23.7–30.9).
Table 1.
Characteristics of the study participants (n = 593).
| Variable | Participants (%) † | Hokkaido University Students (%) |
|---|---|---|
| Sex | ||
| Male | 401 (68.0) | 8032 (71.3) |
| Female | 190 (32.0) | 3234 (28.7) |
| Age | ||
| 18 and 19 years | 197 (33.6) | NA |
| ≥20 years | 390 (66.4) | NA |
| Grade/Year | ||
| Freshman | 65 (11.0) | 2668 (24.0) |
| Other years | 527 (88.9) | 8598 (76.0) |
| Faculty | ||
| Medicine and Healthcare * | 56 (10.0) | 1126 (10.0) |
| Other | 504 (90.0) | 10 140 (90.0) |
| Place of birth | ||
| Hokkaido | 164 (27.8) | 816 (32.0) |
| Elsewhere | 427 (72.3) | 1748 (68.0) |
| Monthly allowance from parents | ||
| Received | 402 (81.2) | NA |
| Not received | 93 (18.8) | NA |
| Scholarship | ||
| Received | 117 (31.1) | NA |
| Not received | 259 (68.9) | NA |
| Parental education (father) | ||
| High school level or lower | 139 (24.0) | NA |
| University level or higher | 441 (76.0) | NA |
| Parental education (mother) | ||
| High school level or lower | 226 (38.8) | NA |
| University level or higher | 356 (61.2) | NA |
| Extracurricular activity | ||
| Yes | 519 (88.4) | NA |
| No | 68 (11.6) | NA |
| Vaccination status | ||
| Vaccinated | 162 (27.3) | NA |
| Unvaccinated | 431 (72.3) | NA |
NA = data not available; * Medicine and Healthcare indicates the faculties of Medicine, Health, Pharmacy, and Dentistry; † the sample size of the participants was 593, but for each item there were a small number of missing answers, resulting in <593 answers.
Table 2 summarizes the univariate relationship between influenza vaccine uptake and the surveyed variables. Younger age (p < 0.0001) and being a freshman (p < 0.0001) were significantly associated with vaccine uptake, and the OR of vaccination among these groups was 2.7 (95% CI: 1.9–3.9) and 11.3 (95% CI: 6.2–20.7) times greater, respectively, than for remainders. Students who belonged to the Faculty of Medicine or who were involved in other healthcare faculties (i.e., Health, Pharmacy, and Dentistry) were more likely to be vaccinated than students in other faculties (OR = 2.5; 95% CI: 1.5–4.1; p < 0.001), and students born in Hokkaido were also more likely to be vaccinated (OR = 1.8; 95% CI: 1.2, 2.7; p < 0.0001). Students engaging in extracurricular activities were less likely to be vaccinated than students not engaging in extracurricular activities (OR = 0.3; 95% CI: 0.2–0.5); p < 0.0001). Sex, monthly allowance, scholarship, and parental education levels were not associated with vaccine uptake.
Table 2.
Frequency of influenza vaccination according to Hokkaido University students’ characteristics.
| Variable | Vaccinated (%) | Unvaccinated (%) | p-Value | OR* (95% Cl**) |
|---|---|---|---|---|
| Sex | ||||
| Male | 107 (26.7) | 294 (73.3) | ||
| Female | 54 (28.4) | 136 (71.6) | 0.66 | 0.9 (0.6–1.3) |
| Age | ||||
| 18 and 19 years | 81 (41.1) | 116 (58.9) | ||
| ≥20 years | 80 (20.5) | 310 (79.5) | <0.0001 | 2.7 (1.9–3.9) |
| Grade/Year | ||||
| Freshman | 49 (75.4) | 16 (24.6) | ||
| Other years | 112 (21.3) | 415 (78.8) | <0.0001 | 11.3 (6.2–20.7) |
| Faculty | ||||
| Medicine and Healthcare * | 35 (44.3) | 44 (55.7) | ||
| Other faculties | 116 (24.1) | 365 (75.9) | <0.0001 | 2.5 (1.5–4.1) |
| Place of birth | ||||
| Hokkaido | 60 (36.6) | 104 (63.4) | ||
| Elsewhere | 102 (23.9) | 325 (76.1) | <0.0001 | 1.8 (1.2–2.7) |
| Monthly allowance from parents | ||||
| Received | 102 (25.4) | 300 (74.6) | ||
| Not received | 27 (29.0) | 66 (71.0) | 0.47 | 0.8 (0.5–1.4) |
| Scholarship | ||||
| Received | 30 (25.6) | 87 (74.4) | ||
| Not received | 72 (27.8) | 187 (72.2) | 0.66 | 0.9 (0.5–1.5) |
| Parental education (father) | ||||
| High school level or lower | 38 (27.3) | 101 (72.5) | ||
| University level or higher | 116 (26.3) | 325 (73.7) | 0.81 | 1.1 (0.7–1.6) |
| Parental education (mother) | ||||
| High school level or lower | 60 (26.6) | 166 (73.5) | ||
| University level or higher | 96 (27.0) | 260 (73.0) | 0.91 | 1.0 (0.7–1.4) |
| Extracurricular activity | ||||
| Yes | 121 (23.3) | 398 (76.7) | ||
| No | 36 (52.9) | 32 (47.1) | <0.0001 | 0.3 (0.2–0.5) |
p-value, chi-square test; * OR = odds ratio of being vaccinated if a student was in the category on the first line vs. the second line (e.g., men’s odds ratio of vaccination compared with that of women); ** Cl = confidence interval using Wald’s method.
Table 3 shows the cross-tabulations of the variables that were significantly associated with vaccination during the univariate analysis, with special focus on freshman or not as an explanatory variable. Stratifying grade/year by age (i.e., 18 and 19 years, or ≥20 years), freshmen were more frequently vaccinated than other year levels (OR = 11.4; 95% CI: 5.4–23.9; p < 0.0001) among 18- and 19-year-old students, and no significant association was identified for other cross-tabulated comparisons using age and grade/year. This indicated that age was not associated with vaccination, and whether a student was a freshman among 18- and 19-year-old students determined the vaccination decision. Similarly, when we stratified vaccination coverage by grade/year and place of birth, being born in Hokkaido was positively associated with vaccination only among non-freshman (OR = 2.1; 95% 1.4–3.3; p = 0.0012). Being a freshman was always positively associated with vaccine uptake (p < 0.001) for people from Hokkaido and elsewhere. Stratifying by grade/year and extracurricular activity, extracurricular activity was negatively associated with vaccination (p = 0.01), but the association was opposite among those not engaging in extracurricular activities (p = 0.02). Again, being a freshman was always positively associated with vaccine uptake for both engaging in and not engaging in extracurricular activities.
Table 3.
Cross tabulation of the frequency of vaccination, regarding age, grade/year, birthplace, and extracurricular activity.
| Characteristic | N (%) | Vaccinated (%) | Unvaccinated (%) | p-Value | OR * (95% Cl **) |
|---|---|---|---|---|---|
| Age | |||||
| Freshman | |||||
| 18 and 19 years | 58 (89.2) | 46 (79.3) | 12 (20.7) | 0.06 | 5.1 (1.0–26.0) |
| ≥20 years | 7 (10.8) | 3 (42.9) | 4 (57.1) | ||
| Other ages | |||||
| 18 and 19 years | 139 (26.7) | 35 (25.2) | 104 (74.8) | 0.23 | 1.4 (0.9–2.1) |
| ≥20 years | 382 (73.3) | 76 (19.9) | 306 (80.1) | ||
| 18 and 19 years | |||||
| Freshman | 58 (29.4) | 46 (79.3) | 12 (20.7) | <0.0001 | 11.4 (5.4–23.9) |
| Other years | 139 (70.6) | 35 (25.2) | 104 (74.8) | ||
| ≥20 years | |||||
| Freshman | 7 (1.8) | 3 (42.9) | 4 (57.1) | 0.15 | 3.0 (0.7–13.8) |
| Other years | 382 (98.2) | 76 (19.9) | 306 (80.1) | ||
| Place of birth | |||||
| Freshman | |||||
| Hokkaido | 19 (30.0) | 15 (79.0) | 4 (21.1) | 1.00 | 1.2 (0.3–4.4) |
| Elsewhere | 45 (70.3) | 34 (75.6) | 11 (24.4) | ||
| Other years | |||||
| Hokkaido | 145 (27.6) | 45 (31.0) | 100 (69.0) | 0.0012 | 2.1 (1.4–3.3) |
| Elsewhere | 381 (72.4) | 67 (17.6) | 314 (82.4) | ||
| Hokkaido | |||||
| Freshman | 19 (11.6) | 15 (79.0) | 4 (21.1) | <0.0001 | 8.3 (2.6–26.5) |
| Other years | 145 (88.4) | 45 (31.0) | 100 (69.0) | ||
| Elsewhere | |||||
| Freshman | 45 (10.6) | 34 (75.6) | 11 (24.4) | <0.0001 | 14.5 (7.0–30.0) |
| Other years | 381 (89.4) | 67 (17.6) | 314 (82.4) | ||
| Extracurricular activity | |||||
| Freshman | |||||
| Yes | 18 (30.0) | 9 (50.0) | 9 (50.0) | 0.01 | 0.2 (0.1–0.7) |
| No | 42 (70.0) | 35 (83.3) | 7 (16.7) | ||
| Other years | |||||
| Yes | 500 (95.1) | 111 (22.2) | 389 (77.8) | 0.02 | 7.1 (1.0–53.2) |
| No | 26 (4.9) | 1 (3.9) | 25 (96.2) | ||
| Extracurricular activity (Yes) | |||||
| Freshman | 18 (3.5) | 9 (50.0) | 9 (50.0) | 0.01 | 3.5 (1.4–9.0) |
| Other years | 500 (96.5) | 111 (22.2) | 389 (77.8) | ||
| Extracurricular activity (No) | |||||
| Freshman | 42 (61.8) | 35 (83.3) | 7 (16.7) | <0.0001 | 125 (14.5–1080.9) |
| Other years | 26 (38.2) | 1 (3.9) | 25 (96.2) |
p-value, Fisher’s exact test; * OR = odds ratio of being vaccinated if a student was in the category on the first line vs. the second line; ** Cl = confidence interval using Wald’s method.
Table 4 shows the cross-tabulations of the variables that were significantly associated with vaccination during the univariate analysis, with special focus on medicine and healthcare faculties or other faculty as an explanatory variable. Regardless of whether a student was in a medicine or healthcare faculty, being a freshman was a predictor of vaccination (p = 0.04 vs. < 0.0001, respectively, for medicine and healthcare vs. other faculties). Being a non-freshmen in medicine and healthcare faculties was a positive predictor of vaccination (p < 0.0001; OR = 3.1; 95% CI: 1.8–5.3). Students from Hokkaido were more likely to be vaccinated only among those not studying medicine or healthcare (p < 0.03; OR = 1.7; 95% CI: 1.0–2.6), and among students raised in locations other than Hokkaido, students in medicine and healthcare were more likely to be vaccinated than students in other faculties (p = 0.01; OR = 2.5 (95% CI: 1.3–4.8)). Among students other than those in medicine and healthcare, engaging in extracurricular activities was a negative predictor of vaccination (p < 0.0001; OR = 0.2; 95% CI: 0.1–0.4), and among students engaging in extracurricular activities, students in medicine and healthcare were more likely to be vaccinated than those in other faculties (p = 0.0002; OR = 2.9; 95% CI: 1.7–5.0).
Table 4.
Cross tabulation of vaccination frequency regarding grade/year, medicine and healthcare major, birthplace, and extracurricular activity.
| Characteristic | N (%) | Vaccinated (%) | Unvaccinated (%) | p-Value | OR * (95% Cl **) |
|---|---|---|---|---|---|
| Freshman | |||||
| Medicine and Healthcare *** | |||||
| Freshman | 7 (8.9) | 6 (85.7) | 1 (14.3) | 0.04 | 8.9 (1.0–77.8) |
| Other faculty | 72 (91.1) | 29 (40.3) | 43 (59.7) | ||
| Other than medicine and healthcare faculty |
|||||
| Freshman | 53 (11.0) | 39 (73.6) | 14 (26.4) | <0.0001 | 12.9 (6.7–24.9) |
| Other faculty | 427 (89.0) | 76 (17.8) | 351 (82.2) | ||
| Freshman | |||||
| Medicine and healthcare | 7 (11.7) | 6 (85.7) | 1 (14.3) | 0.67 | 2.2 (0.2–19.5) |
| Other than medicine and healthcare faculty |
53 (88.3) | 39 (73.6) | 14 (26.4) | ||
| Other than freshman | |||||
| Medicine and healthcare | 72 (14.4) | 29 (40.3) | 43 (59.7) | <0.0001 | 3.1 (1.8–5.3) |
| Other than medicine and healthcare faculty |
427 (85.6) | 76 (17.8) | 351 (82.2) | ||
| Place of birth | |||||
| Medicine and healthcare | |||||
| Hokkaido | 33 (41.8) | 16 (48.5) | 17 (51.5) | 0.65 | 1.3 (0.5–3.3) |
| Elsewhere | 46 (58.2) | 19 (41.3) | 27 (58.7) | ||
| Other than medicine and healthcare faculty |
|||||
| Hokkaido | 117 (24.4) | 37 (31.6) | 80 (68.4) | 0.03 | 1.7 (1.0–2.6) |
| Elsewhere | 363 (75.6) | 79 (21.8) | 284 (78.2) | ||
| Hokkaido | |||||
| Medicine and healthcare | 33 (22.0) | 16 (48.5) | 17 (51.5) | 0.10 | 2.0 (0.9–4.5) |
| Other faculty | 117 (78.0) | 37 (31.6) | 80 (68.4) | ||
| Elsewhere | |||||
| Medicine and healthcare | 46 (11.3) | 19 (41.3) | 27 (58.7) | 0.01 | 2.5 (1.3–4.8) |
| Other faculty | 363 (88.8) | 79 (21.8) | 284 (78.2) | ||
| Extracurricular activity | |||||
| Medicine and healthcare | |||||
| Yes | 69 (89.6) | 29 (42.0) | 40 (58.0) | 0.45 | 0.4 (0.1–2.0) |
| No | 8 (10.4) | 5 (62.5) | 3 (37.5) | ||
| Other than medicine and healthcare faculty | |||||
| Yes | 421 (88.3) | 84 (20.0) | 337 (80.1) | <0.0001 | 0.2 (0.1–0.4) |
| No | 56 (11.7) | 28 (50.0) | 28 (50.0) | ||
| Extracurricular activity (Yes) | |||||
| Medicine and healthcare | 69 (14.1) | 29 (42.0) | 40 (58.0) | 0.0002 | 2.9 (1.7–5.0) |
| Other faculty | 421 (85.9) | 84 (20.0) | 337 (80.1) | ||
| Club activity (No) | |||||
| Medicine and healthcare | 8 (12.5) | 5 (62.5) | 3 (37.5) | 0.71 | 1.7 (0.4–7.7) |
| Other faculty | 56 (87.5) | 28 (50.0) | 28 (50.0) |
p-value, Fisher’s exact test; * OR = odds ratio of being vaccinated if a student was in the category on the first line compared with the second line; ** Cl = confidence interval using Wald’s method; *** Faculties of Medicine, Health, Pharmacy, and Dentistry.
Table 5 summarizes students’ attitudes toward influenza and influenza vaccination. Four notable negative predictors were identified, namely, (i) not worried about the risk of infection (p = 0.04; OR = 0.7; 95% CI: 0.4–1.0), (ii) dislike injections or injections are painful (p = 0.01; OR = 0.2; 95% CI: 0.1–0.8), (iii) not worried about the clinical seriousness of influenza (p = 0.005; OR = 0.4; 95% CI: 0.2–0.8), and (iv) concerned with the cost of the influenza vaccine (p = 0.004; OR = 0.6; 95% CI: 0.4–0.8). Among the other potential explanations for not choosing vaccination, limited effectiveness, vaccination status of the surrounding people, potential adverse reaction, parental advice, and available time were not associated with receiving influenza vaccination.
Table 5.
Frequency of vaccination by participants’ attitudes toward influenza and vaccination.
| Characteristic | Vaccinated (%) |
Unvaccinated (%) |
p-Value | OR * (95% Cl **) |
|---|---|---|---|---|
| 1. Not worried about influenza | 58 (22.9) | 195 (77.1) | 0.04 | 0.7 (0.4–1.0) |
| Otherwise | 104 (30.6) | 236 (69.4) | ||
| 2. Dislike injection or pain with injection | 3 (8.6) | 32 (91.4) | 0.01 | 0.2 (0.1–0.8) |
| Otherwise | 159 (28.5) | 399 (71.5) | ||
| 3. Not worried about the clinical seriousness of influenza |
12 (14.6) | 70 (85.4) | 0.0049 | 0.4 (0.2–0.8) |
| Otherwise | 150 (29.4) | 361 (70.7) | ||
| 4. Perceived limited effectiveness of vaccination |
69 (31.1) | 153 (68.9) | 0.13 | 1.3 (0.9–1.9) |
| Otherwise | 93 (25.1) | 277 (74.9) | ||
| 5. Concerned with the cost of the influenza vaccine |
44 (20.3) | 173 (79.7) | 0.004 | 0.6 (0.4–0.8) |
| Otherwise | 118 (31.4) | 258 (68.6) | ||
| 6. Worried about having an allergic reaction |
10 (27.8) | 26 (72.2) | 1.00 | 1.0 (0.5–2.2) |
| Otherwise | 152 (27.3) | 405 (72.7) | ||
| 7. Would decide depending on the vaccination status of surrounding people |
20 (25.3) | 59 (74.7) | 0.67 | 0.9 (0.5–1.5) |
| Otherwise | 142 (27.3) | 372 (72.4) | ||
| 8. Vaccination depends on having a nearby healthcare facility |
31 (30.4) | 71 (69.6) | 0.46 | 1.2 (0.8–1.9) |
| Otherwise | 131 (26.7) | 360 (73.3) | ||
| 9. Worried about adverse reaction following vaccination |
22 (33.3) | 44 (66.7) | 0.24 | 1.4 (0.8–2.4) |
| Otherwise | 140 (26.6) | 387 (73.4) | ||
| 10. General health status | 40 (28.8) | 99 (71.2) | 0.66 | 1.1 (0.7–1.7) |
| Otherwise | 122 (26.9) | 332 (73.1) | ||
| 11. Encouragement from parents | 31 (30.1) | 72 (69.9) | 0.54 | 1.2 (0.7–1.9) |
| Otherwise | 131 (26.7) | 359 (73.3) | ||
| 12. Vaccination depends on available time | 48 (23.9) | 153 (76.1) | 0.21 | 0.8 (0.5–1.1) |
| Otherwise | 114 (29.1) | 278 (70.9) |
* OR = odds ratio of being vaccinated if a student was in the category on the first line compared with the second line; ** Cl = confidence interval using Wald’s method.
4. Discussion
This study was a cross-sectional survey of influenza vaccination history among Hokkaido University students, which identified a vaccination coverage rate of 27.3% among approximately 600 students. While the overall vaccination coverage could be affected by the year of the study, univariate and cross-tabulation analyses showed that being a freshman was a strong positive predictor of vaccination, and that freshmen were approximately 10 times more frequently vaccinated than students in other years. Among non-freshmen, students belonging to medicine and healthcare-related faculties were three times more frequently vaccinated than students in other faculties, and the coverage of students raised in Hokkaido was twice as high as that for students from other locales. Moreover, engaging in extracurricular activities was a positive predictor of vaccination among students other than freshmen. Regarding students’ attitudes toward influenza vaccination, students paying little attention to the risks of infection and the severity of influenza and those concerned about injection-related pain and vaccination cost were less likely to be vaccinated. To our knowledge, our study is the first to explore the demographic and sociocultural factors related to influenza vaccination in a university setting in Japan with students enrolled in diverse disciplines, including natural and social sciences.
A remarkable finding in the present study was the high vaccination coverage (75.4%) among freshmen who completed the entrance examination for Hokkaido University from February to March, 2019 (i.e., 1–2 months prior to the survey). In Japan, there is a very competitive process to enter high-ranking universities [47,48], and considering that high school students are explicitly advised to undertake influenza vaccination, we believe that high school students’ decisions for vaccination were associated with the entrance examination, which takes place in the winter season during high influenza activity. A relatively high vaccination coverage of 31.5% among freshmen was also reported from the USA [49]. Of course, parents could have encouraged students to be vaccinated in advance of their own decision. In addition to the high coverage in freshman, students in medicine and healthcare faculties were more likely to be vaccinated among non-freshman (40.3%), perhaps reflecting their potentially higher exposure at healthcare facilities. Belonging to medicine and healthcare faculties was not associated with vaccination among freshman, because many freshmen do not belong to the medicine and healthcare faculties in their first year, but can choose to proceed to these faculties in their second year. It is also true that freshmen in medicine and healthcare faculties have very little chance to interact with patients, not motivating them for vaccination. The estimated coverage among students in medicine and healthcare faculties was lower but comparable to that in Australia (53.8%) [41] and similar to the rate in Southern California (43.0%) [35]. Making the vaccination compulsory increases vaccination coverage among healthcare students [39,41]. These determinants of vaccination i.e., freshman and medical student, are not translatable to all related studies, but our findings were similar to those in previous studies [35,41,47,48,49].
Importantly, we also found that students other than freshmen were more likely to be vaccinated if they were from Hokkaido (31.0%) and if they engaged in extracurricular activities (22.2%). The majority of students from Hokkaido live with their parents and commute to the university, or at least have frequent chances to visit their homes on the weekends. Economically stable living conditions and continued exposure to health-related input from their family members could have contributed to the elevated vaccination coverage. Extracurricular activity increases the chance to interact with other students; however, this activity was not associated with freshmen because they have yet to decide on an extracurricular activity. As implied by social epidemiological studies [19,50,51,52], the level of social capital promotes healthy decision-making. In particular, students engaging in social interactions via extracurricular activities, including extracurricular campus activities and volunteering in local community service, have higher vaccination coverage rates [34]. Educating students regarding their risk self-assessment may promote vaccination [37].
Unvaccinated participants provided their reasons for considering or not considering vaccination, including injection pain, perceived risk of influenza and its severe complications, and the cost of vaccination. Appropriate education from university healthcare workers could temporarily eliminate these concerns, but education alone does not directly lead to behavioral change toward vaccination [19,35,37,53]. When devising an appropriate health recognition model for students, it is essential to develop diverse opportunities for communication at home, in extracurricular activities, and other lifestyle environments on-campus [31,32,34]. There are four different transtheoretical models/components for behavioral change, i.e., (i) balancing the advantages vs. disadvantages of change, (ii) ensuring self-efficacy, (iii) promoting and supporting experiential and behavioral processes, and (iv) accounting for stages of change [54,55,56,57,58]. In our setting, (i) balancing advantages and disadvantages could affect the results. Consciousness raising and relieving students’ concerns could be attained by understanding that influenza can be fatal, and possible consideration of vaccination at the university health center at low cost could lead to environmental reevaluation. Although a radical option, (ii) mandating compulsory vaccination for all students could act as a counter-conditioning factor as part of (iii) the process of behavioral change. Such a program could potentially be aligned with the annual health check-up.
Strengths of our study include (i) a balanced involvement of both freshmen and others via questionnaire survey at the very beginning of an academic year, (ii) the study at a single university where all faculty buildings are built on the same campus, and (iii) good representation of the entire university student body including accurate sex ratio representation. Limitations of the study must be discussed. First, this study had a cross-sectional design, and thus, temporality was not assessed, and causal relationships remain unknown. Second, potential systematic biases of our study include (i) responder selection bias (e.g., those accepting our survey were likely to have been vaccinated) and (ii) interviewer bias (e.g., students who were more accessible to the authors could have shared some propensity of vaccination tendency. Both could have elevated the vaccination coverage. Although we did not explicitly address confounders, we at least examined potential interaction for each combination of two variables. Third, we performed this survey in April 2019, the first month of the academic year in Japan. For this reason, the extracurricular activities and future majors (and faculties) of the freshmen remained largely unknown, making these items difficult to assess. Fourth, while we hypothesized that the most important reason for vaccination among freshmen was to avoid influenza during the entrance examination, we missed the chance to ask whether students would be keen to receive vaccination for some other event, especially important events associated with university life. Fifth, the sample size was limited to approximately 600, and we were unable to identify more precise characteristics (e.g., vaccination coverage of a specific faculty other than medicine and healthcare). Sixth, the questionnaire could have been revised to explore the possible contributors to behavioral change (e.g., factors associated with attitudes and decision-making processes) based on transtheoretical models.
Despite these limitations, we believe that we have successfully shown that an important life event (e.g., entrance examination) can enormously elevate vaccination coverage. In the future, university curriculum designs could account for our finding and organize key events during the winter season. Also, considering the concerns over the cost of vaccination, an aggressive option is to implement compulsory vaccination free of charge, perhaps starting it among medicine and healthcare students. In addition to providing students with the tools to assess their own risk, consciousness raising via appropriate understanding of influenza and its severity and offering vaccination at university health centers at a reasonable cost would promote vaccine acceptance.
5. Conclusions
The present study involved a cross-sectional survey of influenza vaccination history among Hokkaido University students. The vaccination coverage was 27.3%, and freshmen were approximately 10 times more frequently vaccinated than students in other years. Among students other than freshmen, belonging to medicine and healthcare faculties, engaging in extracurricular activities, and being raised in Hokkaido were positive predictors of vaccination. Consciousness raising via appropriate understanding of influenza and its severity and offering vaccination at university health centers at a reasonable cost would promote vaccine acceptance.
Acknowledgments
We thank Jane Charbonneau, DVM, from Edanz Group (www.edanzediting.com/ac) for editing a draft of this manuscript.
Supplementary Materials
The following are available online at https://www.mdpi.com/2076-393X/8/1/52/s1, Table S1: English translation of the questionnaire.
Author Contributions
Conceptualization, Y.K. and H.N.; methodology, H.N.; validation, Y.K. and H.N.; formal analysis, Y.K. and H.N.; investigation, Y.K. and H.N.; resources, Y.K. and H.N.; data curation, Y.K.; writing—original draft preparation, Y.K. and H.N.; writing—review and editing, Y.K. and H.N.; visualization, Y.K.; supervision, H.N.; project administration, H.N.; funding acquisition, H.N. All authors have read and agreed to the published version of the manuscript.
Funding
H.N. received funding from the Japan Agency for Medical Research and Development (AMED) [grant number: JP18fk0108050], the Japan Society for the Promotion of Science (JSPS) KAKENHI [grant numbers, H.N.: 17H04701, 17H05808, 18H04895 and 19H01074], the Inamori Foundation, and the Japan Science and Technology Agency (JST) CREST program [grant number: JPMJCR1413].
Conflicts of Interest
The authors declare no conflict of interest.
References
- 1.Centers for Disease Control and Prevention About flu. [(accessed on 14 November 2019)]; Available online: http://www.cdc.gov/flu/about/index.html.
- 2.Centers for Disease Control and Prevention Flu Symptoms & Diagnosis. [(accessed on 14 November 2019)]; Available online: http://www.cdc.gov/flu/symptoms/symptoms.html.
- 3.Centers for Disease Control and Prevention Influenza (Flu). People at High Risk for Flu Complications. Information for Specific High Risk Groups. [(accessed on 14 November 2019)]; Available online: http://www.cdc.gov/flu/highrisk/indx.html.
- 4.Reed C., Chaves S.S., Kirley P.D., Emerson R., Aragon D., Hancock E.B., Butler L., Baumbach J., Hollick G., Bennett N.M., et al. Estimating influenza disease burden from population-based surveillance data in the United States. PLoS ONE. 2015;10:e0118369. doi: 10.1371/journal.pone.0118369. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Nichol K.L., Mallon K.P., Mendelman P.M. Cost benefit of influenza vaccination in healthy, working adults: an economic analysis based on the results of a clinical trial of trivalent live attenuated influenza virus vaccine. Vaccine. 2003;21:2207–2217. doi: 10.1016/S0264-410X(03)00029-X. [DOI] [PubMed] [Google Scholar]
- 6.Nichol K.L., D’Henlly S., Ehlinger E.P. Influenza vaccination among college and university students: impact on influenza like illness, health care use, and impaired school performance. Arch. Pediatr. Adolesc. Med. 2008;162:1113–1118. doi: 10.1001/archpedi.162.12.1113. [DOI] [PubMed] [Google Scholar]
- 7.Molinari N.A., Sanchez I.R.O., Mesonnier M.L., Thompson W.W., Wortley P.M., Weintraub E., Bridges C.B. The annual impact of seasonal influenza in the US: measuring disease burden and costs. Vaccine. 2007;25:5086–5096. doi: 10.1016/j.vaccine.2007.03.046. [DOI] [PubMed] [Google Scholar]
- 8.Vemula S.V., Sayedahmed E.E., Sambhara S., Mittal S.K. Vaccine approaches conferring cross-protection against influenza viruses. Expert Rev. Vaccines. 2017;16:1141–1154. doi: 10.1080/14760584.2017.1379396. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Marczinski C.A. Perceptions of pandemic influenza vaccines. Hum. Vaccin. Immunother. 2012;8:275–278. doi: 10.4161/hv.18457. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Nishiura H., Chavez C.C., Safan M., Chowell G. Transmission potential of the new influenza A (H1N1) virus and its age-specificity in Japan. Euro Surveill. 2009;14:1–4. doi: 10.2807/ese.14.22.19227-en. [DOI] [PubMed] [Google Scholar]
- 11.Nishiura H., Cook A.R., Cowling B.J. Assortativity and the probability of epidemic extinction: a case study of pandemic influenza A (H1N1-2009) Interdiscip. Perspect. Infect. Dis. 2011;2011:194507. doi: 10.1155/2011/194507. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Fukuda E., Kokubo S., Tanimoto J., Wang Z., Hagishima A., Ikegaya N. Risk assessment for infectious disease and its impact on voluntary vaccination behavior in social networks. Chaos Soliton. Fract. 2014;68:1–9. doi: 10.1016/j.chaos.2014.07.004. [DOI] [Google Scholar]
- 13.Nichol K.L., Tummers K., Leitzel A.H., Marsh J., Moynihan M., McKelvey S. Modeling seasonal influenza outbreak in a closed college campus: impact of pre-season vaccination, in-season vaccination and holidays/breaks. PLoS ONE. 2010;5:e9548. doi: 10.1371/journal.pone.0009548. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Sugaya N. A review of the indirect protection of younger children and the elderly through a mass influenza vaccination program in Japan. Expert Rev. Vaccines. 2014;13:1563–1570. doi: 10.1586/14760584.2014.951036. [DOI] [PubMed] [Google Scholar]
- 15.Sugaya N., Takeuchi Y. Mass vaccination of schoolchildren against influenza and its impact on the influenza-associated mortality rate among children in Japan. Clin. Infect. Dis. 2005;41:939–947. doi: 10.1086/432938. [DOI] [PubMed] [Google Scholar]
- 16.Matsui D., Shigeta M., Ozasa K., Kuriyama N., Watanabe I., Watanabe Y. Factors associated with influenza vaccination status of residents of a rural community in Japan. BMC Public Health. 2011;11:149. doi: 10.1186/1471-2458-11-149. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Nobuhara H., Watanabe Y., Miura Y. Estimated influenza vaccination rates in Japan. Nihon Koshu Eisei Zasshi. 2014;61:354–359. (In Japanese) [PubMed] [Google Scholar]
- 18.Kudo Y., Kawano K., Kido Y., Kodama M., Chotaro F. The need for promoting educational activities regarding prevention strategies for influenza among college students. J. Gen. Fam. Med. 2014;37:281–284. [Google Scholar]
- 19.Bednarczyk R.A., Chu S.L., Sickler H., Shaw J., Nadeau J.A., McNutt L.A. Low uptake of influenza vaccine among university students: evaluating predictors beyond cost and safety concerns. Vaccine. 2015;33:1659–1663. doi: 10.1016/j.vaccine.2015.02.033. [DOI] [PubMed] [Google Scholar]
- 20.Hara M., Hirota Y. Basic principle of population-based cohort study evaluate influenza vaccine effectiveness among elderly Japanese. Vaccine. 2017;35:4791–4795. doi: 10.1016/j.vaccine.2017.07.002. [DOI] [PubMed] [Google Scholar]
- 21.Hirota Y., Kaji M. History of influenza vaccination programs in japan. Vaccine. 2008;26:6451–6454. doi: 10.1016/j.vaccine.2008.06.042. [DOI] [PubMed] [Google Scholar]
- 22.Reichert T.A., Sugaya N., Fedson D.S., Glezen W.P., Simonsen L., Tashiro M. The Japanese experience with vaccinating schoolchildren against influenza. N. Engl. J. Med. 2001;344:889–896. doi: 10.1056/NEJM200103223441204. [DOI] [PubMed] [Google Scholar]
- 23.Charu V., Viboud C., Simonsen L., Sturm-Ramirez K., Shinjoh M., Chowell G., Miller M., Sugaya N. Influenza-related mortality trends in Japanese and American seniors: evidence for the indirect mortality benefits of vaccinating school children. PLoS ONE. 2011;6:e26282.:e26282. doi: 10.1371/journal.pone.0026282. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Plans-Rubio P. The vaccination coverage required to establish herd immunity against influenza viruses. Prev. Med. 2012;55:72–77. doi: 10.1016/j.ypmed.2012.02.015. [DOI] [PubMed] [Google Scholar]
- 25.Kawahara Y., Nishiura H. Hypothetical scenario analysis of influenza vaccination in Sapporo city and Hokkaido University using a mathematical model. Hokkaido J. Public Health. 2018;32:45–51. [Google Scholar]
- 26.Nishiura H., Ejima K., Mizumoto K., Nakaoka S., Inaba H., Imoto S., Yamaguchi R., Saito M.M. Cost-effective length and timing of school closure during an influenza pandemic depend on the severity. Theor. Biol. Med. Model. 2014;11:1–14. doi: 10.1186/1742-4682-11-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Nichol K.L., Margolis K.L., Wuorenma J., Von Sternberg T. The efficacy and cost effectiveness of vaccination against influenza among elderly persons living in the community. N. Engl. J. Med. 1994;331:778–784. doi: 10.1056/NEJM199409223311206. [DOI] [PubMed] [Google Scholar]
- 28.Iwasa T., Wada K. Reasons for and against receiving influenza vaccination in a working age population in Japan: a national cross-sectional study. BMC Public Health. 2013;13:647. doi: 10.1186/1471-2458-13-647. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Wada K., Smith D.R. Mistrust surrounding vaccination recommendations by the Japanese government: results from a national survey of working-age individuals. BMC Public Health. 2015;15:426. doi: 10.1186/s12889-015-1772-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Kawai S., Nanri S., Ban E., Inokuchi M., Tanaka T., Tokumura M., Kimura K., Sugaya N. Influenza vaccination of schoolchildren and influenza outbreaks in a school. Clin. Infect. Dis. 2011;53:130–136. doi: 10.1093/cid/cir336. [DOI] [PubMed] [Google Scholar]
- 31.Shropshire A.M., Hotchkiss R.B., Andrews U.K. Mass media campaign impacts influenza vaccine obtainment of university students. J. Am. Coll. Health. 2013;61:435–643. doi: 10.1080/07448481.2013.830619. [DOI] [PubMed] [Google Scholar]
- 32.Huang J.J., Francesconi M., Cooper M.H., Covello A., Guo M., Gharib S.D. Community health workers on a college campus: effects on influenza vaccination. J. Am. Coll. Health. 2018;66:317–323. doi: 10.1080/07448481.2018.1440582. [DOI] [PubMed] [Google Scholar]
- 33.Hashmi S., D’Ambrosio L., Diamond D.V., Jalali M.S., Finkelstein S.N., Larson R.C. Preventive behaviors and perceptions of influenza vaccination among a student university population. J. Public Health. 2016;38:739–745. doi: 10.1093/pubmed/fdv189. [DOI] [PubMed] [Google Scholar]
- 34.Poehling K.A., Blocker J., Edward H., Peters T.R., Wolfson M. 2009-2010 seasonal influenza vaccination coverage among college students from 8 universities in North Carolina. J. Am. Coll. Health. 2012;60:541–547. doi: 10.1080/07448481.2012.700973. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Rogers C.J., Bahr K.O., Benjamin S.M. Attitudes and barriers associated with seasonal influenza vaccination uptake among public health students; a cross-sectional study. BMC Public Health. 2018;18:1131. doi: 10.1186/s12889-018-6041-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Lehmann B.A., Ruiter R.A.C., Wicker S., Chapman G., Kok G. Medical students’ attitude towards influenza vaccination. BMC Infect. Dis. 2015;15:185. doi: 10.1186/s12879-015-0929-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Afonso N., Kavanagh M., Swanberg S. Improvement in attitudes toward influenza vaccination in medical students following an integrated curricular intervention. Vaccine. 2014;32:502–506. doi: 10.1016/j.vaccine.2013.11.043. [DOI] [PubMed] [Google Scholar]
- 38.Rebmann T., Elliott M.B., Artman D. Missouri K-12 school disaster and biological event preparedness and seasonal influenza vaccination among school nurses. Am. J. Infect. Control. 2015;43:1028–1034. doi: 10.1016/j.ajic.2015.06.009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Cheung K., Ho S.M.S., Lam W. Factors affecting the willingness of nursing students to receive annual seasonal influenza vaccination: a large-scale cross- sectional study. Vaccine. 2017;35:1482–1487. doi: 10.1016/j.vaccine.2017.02.001. [DOI] [PubMed] [Google Scholar]
- 40.Tuohetamu S., Pang M., Nuer X., Mahemuti M.P., Qin Y., Peng Z., Zheng J., Yu H., Feng L., Feng Z. The knowledge, attitudes and practices on influenza among medical college students in Northwest China. Hum. Vaccin. Immunother. 2017;13:1688–1692. doi: 10.1080/21645515.2017.1293769. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41.Walker L., Newall A., Heywood A.E. Knowledge, attitudes and practices of Australian medical students towards influenza vaccination. Vaccine. 2016;34:6193–6199. doi: 10.1016/j.vaccine.2016.10.074. [DOI] [PubMed] [Google Scholar]
- 42.Gallone M.S., Gallone M.F., Cappelli M.G., Fortunato F., Martinelli D., Quarto M., Prato R., Tafuri S. Medical students’ attitude toward influenza vaccination: results of a survey in the University of Bari (Italy) Hum. Vaccin. Immunother. 2017;13:1937–1941. doi: 10.1080/21645515.2017.1320462. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 43.Kelly D.A., Macey D., Mak D.B. Annual influenza vaccination. Uptake, barriers, and enablers among student health care providers at the University of Notre Dame Australia, Fremantle. Human. Vaccin. Immunother. 2014;10:1930–1934. doi: 10.4161/hv.29071. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44.Abbas K.M., Kang G.J., Chen D., Were S.R., Marathe A. Demographics, perceptions, and socioeconomic factors affecting influenza vaccination among adults in the United States. Peer J. 2018;6:e5171. doi: 10.7717/peerj.5171. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45.Endrich M.M., Blank P.R., Szucs T.D. Influenza vaccination uptake and socioeconomic determinants in 11 European countries. Vaccine. 2009;27:4018–4024. doi: 10.1016/j.vaccine.2009.04.029. [DOI] [PubMed] [Google Scholar]
- 46.Ramsey M.A., Marczinski C.A. College students’ perceptions of H1N1 flu risk and attitudes toward vaccination. Vaccine. 2011;29:7599–7601. doi: 10.1016/j.vaccine.2011.07.130. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 47.Nagata K., Okubo H., Moji K., Takemoto T. Difference of the 28-Item General Health Questionnaire scores between Japanese high school and university students. Jpn. J. Psychiatry Neurol. 1993;47:575–583. doi: 10.1111/j.1440-1819.1993.tb01802.x. [DOI] [PubMed] [Google Scholar]
- 48.Uno M., Ando E. Aspects of psychologic disorders in Japanese students. Fortschr Neurol Psychiatr. 1991;59:228–233. doi: 10.1055/s-2007-1000698. [DOI] [PubMed] [Google Scholar]
- 49.Ratnapradipa K., Norrenberns R., Turner J.A., Kunerth A. Freshman flu vaccination behavior and intention during a nonpandemic season. Health Promot. Pract. 2017;18:662–671. doi: 10.1177/1524839917712731. [DOI] [PubMed] [Google Scholar]
- 50.Uddin M., Cherkowski G.C., Liu G., Zhang J., Monto A.S., Aiello A.E. Demographic and socioeconomic determinants of influenza vaccination disparities among university students. J. Epidemiol. Community Health. 2010;64:808–813. doi: 10.1136/jech.2009.090852. [DOI] [PubMed] [Google Scholar]
- 51.Nyhan B., Reifler J., Richey S. The role of social networks in influenza vaccine attitudes and intentions among college students in the southeastern United States. J. Adolesc. Health. 2012;51:302–304. doi: 10.1016/j.jadohealth.2012.02.014. [DOI] [PubMed] [Google Scholar]
- 52.Ryan K.A., Fillipp S.L., Gurka M.J., Zirulnik A., Thompson L.A. Understanding influenza vaccine perspectives and hesitancy in university students to promote increased vaccine uptake. Heliyon. 2019;5:e02604. doi: 10.1016/j.heliyon.2019.e02604. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 53.Rodas J.R., Lau C.H., Zhang Z.Z., Griffiths S.M., Luk W.C., Kim J.H. Exploring predictors influencing intended and actual acceptability of the A/H1N1 pandemic vaccine: a cohort study of university students in Hong Kong. Public Health. 2012;126:1007–1012. doi: 10.1016/j.puhe.2012.09.011. [DOI] [PubMed] [Google Scholar]
- 54.Bandura A. Social cognitive theory of self-regulation. Organ. Behav. Hum. Decis. Process. 1991;50:248–287. doi: 10.1016/0749-5978(91)90022-L. [DOI] [Google Scholar]
- 55.Hashemzadeh M., Rahimi A., Farashbandi F.Z., Alavi-Naeini A.M., Daei A. Transtheoretical model of health behavioral change: a systematic review. Iran. J. Nurs. Midwifery Res. 2019;24:83–90. doi: 10.4103/ijnmr.IJNMR_94_17. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 56.Paiva A.L., Lipschitz J.M., Fernandez A.C., Redding C.A., Prochaska J.O. Evaluation of the acceptability and feasibility of a computer-tailored intervention to increase human papillomavirus vaccination among young adult women. J. Am. Coll. Health. 2014;62:32–38. doi: 10.1080/07448481.2013.843534. [DOI] [PubMed] [Google Scholar]
- 57.Prochaska J.O., Butterworth S., Redding C.A., Burden V., Perrin N., Leo M., Flaherty-Robb M., Prochaska J.M. Initial efficacy of MI, TTM tailoring and HRI’s with multiple behaviors for employee health promotion. Prev. Med. 2008;46:226–231. doi: 10.1016/j.ypmed.2007.11.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 58.Painter J.E., Borba C.P., Hynes M., Mays D., Glanz K. The use of theory in health behavior research from 2000 to 2005: A systematic review. Ann. Behav. Med. 2008;35:358–362. doi: 10.1007/s12160-008-9042-y. [DOI] [PubMed] [Google Scholar]
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