The intentions to get vaccinated against influenza and actual vaccine uptake among diabetic patients in Ningbo, China: identifying motivators and barriers

Figures & data

Table 1. Characteristics of survey participants

Demographics	Total (N = 1914)
Age (mean, SD)	65.13 ± 9.75
Gender
Male	740 (38.66)
Female	1174 (61.34)
Monthly income (CNY)
<3000	1449 (75.71)
≥3000	465 (24.29)
Highest level of education attainment
Primary or below	1285 (67.14)
Secondary	589 (30.77)
Tertiary or above	40 (2.09)
Occupation
Executives and professionals	119 (6.22)
Clerks and workers	477 (24.92)
Farmers	983 (51.36)
Economically inactive	335 (17.50)
Marital status
Single/divorced/widowed	262 (13.69)
Married	1652 (86.31)
Region
Rural	804 (42.01)
Urban	1110 (57.99)
Numbers of Comorbidities^a
0	603(31.50)
1	1095(57.21)
≥2	216(11.29)

Data are reported as number of participants(%).

^aComorbidities included chronic respiratory disease, chronic heart disease, cerebrovascular disease, hypertension and cancer.

Figure 1. (a) Intention to receive influenza vaccine among diabetic patients, by select demographics, the 2016/2017 influenza season. (b) Influenza vaccination coverage of diabetic patients, by select demographics, the 2016/2017 influenza season

Table 2. Crosstab of diabetic patients’ intention to get vaccinated and their actual vaccination behavior

	No intention	No clear decision	Moderate intention	High intention	Total
Not vaccinated	690 (100.00)	340 (99.71)	568 (93.27)	166 (60.58)	1764 (92.16)
Vaccinated	0 (0.00)	1 (0.29)	41 (6.73)	108 (39.42)	150 (7.84)
Total	690 (100.00)	341 (100.00)	609 (100.00)	274 (100.00)	1914 (100.00)

Data are reported as number of participants (%).

Table 2. Crosstab of diabetic patients’ intention to get vaccinated and their actual vaccination behavior

	No intention	No clear decision	Moderate intention	High intention	Total
Not vaccinated	690 (100.00)	340 (99.71)	568 (93.27)	166 (60.58)	1764 (92.16)
Vaccinated	0 (0.00)	1 (0.29)	41 (6.73)	108 (39.42)	150 (7.84)
Total	690 (100.00)	341 (100.00)	609 (100.00)	274 (100.00)	1914 (100.00)

Data are reported as number of participants (%).

Table 3. The Summary Health Belief Model responses of survey participants

				Intention to receive influenza vaccination				Influenza vaccination in 2016/2017
HBM Constructs	Item	Level	Total	High (N = 274)	Moderate (N = 609)	No clear (N = 341)	No (N = 690)	Vaccinated (N = 150)	Unvaccinated (N = 1764)
Perceived Susceptibility
Frequency of influenza-like illness	I often had influenza-like illness last year (≥3 times).	Yes	513	99 (19.30)	199 (38.79)	81 (15.79)	134 (26.12)	48 (9.36)	465 (90.64)
		No/not sure	1401	175 (12.49)	410 (29.26)	260 (18.56)	556 (39.69)	102 (7.28)	1299 (92.72)
Susceptibility to influenza	Compared with peers, I am more likely to get influenza.	Yes	479	113 (23.59)	199 (41.54)	63 (13.15)	104 (21.71)	59 (12.32)	420 (87.68)
		No/not sure	1435	161 (11.22)	410 (28.57)	278 (19.37)	586 (40.84)	91 (6.34)	1344 (93.66)
Susceptibility of diabetics	Diabetic patients were more likely to get infection.	Yes	584	131 (22.43)	236 (40.41)	90 (15.41)	127 (21.75)	77 (13.18)	507 (86.82)
		No/not sure	1330	143 (10.75)	373 (28.05)	251 (18.87)	563 (42.33)	73 (5.49)	1257 (94.51)
Perceived Severity
Severe infection	Diabetic patients would get severely sick and even lead to death with influenza infection.	Yes	747	141 (18.88)	266 (35.61)	134 (17.94)	206 (27.58)	77 (10.31)	670 (89.69)
		No/not sure	1167	133 (11.40)	343 (29.39)	207 (17.74)	484 (41.47)	73 (6.26)	1094 (93.74)
Glucose control	Influenza would lead to blood glucose oscillations among diabetic patients.	Yes	747	147 (19.68)	271 (36.28)	127 (17.00)	202 (27.04)	80 (10.71)	667 (89.29)
		No/not sure	1167	127 (10.88)	338 (28.96)	214 (18.34)	488 (41.82)	70 (6.00)	1097 (94.00)
Perceived Benefits
Prevent influenza	Influenza vaccination can prevent influenza infection.	Yes	475	142 (29.89)	157 (33.05)	63 (13.26)	113 (23.79)	104 (21.89)	371 (78.11)
		No/not sure	1439	132 (9.17)	452 (31.41)	278 (19.32)	577 (40.10)	46 (3.20)	1393 (96.80)
Prevent acute complications	Influenza vaccination can prevent acute complications of diabetes.	Yes	378	71 (18.78)	153 (40.48)	64 (16.93)	90 (23.81)	53 (14.02)	325 (85.98)
		No/not sure	1536	203 (13.22)	456 (29.69)	277 (18.03)	600 (39.06)	97 (6.32)	1439 (93.68)
Barriers
Unpreventable of influenza	I do not think influenza can be prevented.	Yes	880	68 (7.73)	250 (28.41)	148 (16.82)	414 (47.05)	10 (1.14)	870 (98.86)
		No/not sure	1034	206 (19.92)	359 (34.72)	193 (18.67)	276 (26.69)	140 (13.54)	894 (86.46)
Safety of vaccine	I was concerned about the safety of the influenza vaccine.	Yes	510	63 (12.35)	140 (27.45)	78 (15.29)	229 (44.90)	32 (6.27)	478 (93.73)
		No/not sure	1404	211 (15.03)	469 (33.40)	263 (18.73)	461 (32.83)	118 (9.05)	1286 (90.95)
Self-efficacy
Payment for vaccine	The influenza vaccine is covered by my/family’s insurance or free for me.	Yes	778	188 (24.16)	428 (55.01)	161 (20.69)	1 (0.13)	115 (14.78)	663 (85.22)
		No/not sure	1136	86 (7.57)	181 (15.93)	180 (15.85)	689 (60.65)	35 (3.08)	1101 (96.92)
Accessibility to vaccine	It is convenient to get the influenza vaccine.	Yes	1519	258 (16.98)	522 (34.36)	287 (18.89)	452 (29.76)	137 (9.02)	1382 (90.98)
		No/not sure	395	16 (4.05)	87 (22.03)	54 (13.67)	238 (60.25)	13 (3.29)	382 (96.71)
Health seeking behaviors	I would go to hospital If I develop symptoms of influenza-like illness, like fever, cough.	Yes	1077	156 (14.48)	385 (35.75)	201 (18.66)	335 (31.10)	100 (9.29)	977 (90.71)
		No/not sure	837	118 (14.10)	224 (26.76)	140 (16.73)	355 (42.41)	50 (5.97)	787 (94.03)
Cues to action
Doctor Recommendation	The healthcare provider recommends that I get vaccinated.	Yes	655	142 (21.68)	263 (40.15)	124 (18.93)	126 (19.24)	111 (16.95)	544 (83.05)
		No/not sure	1259	132 (10.48)	346 (27.48)	217 (17.24)	564 (44.80)	39 (3.10)	1220 (96.90)
Family/friends influence	My friends and/or family recommend that I get vaccinated.	Yes	301	72 (23.92)	121 (40.20)	30 (9.97)	78 (25.91)	41 (13.62)	260 (86.38)
		No/not sure	1613	202 (12.52)	488 (30.25)	311 (19.28)	612 (37.94)	109 (6.76)	1504 (93.24)
Media influence	I get influenza recommendation from the media and/or internet.	Yes	479	94 (19.62)	191 (39.87)	79 (16.49)	115 (24.01)	76 (15.87)	403 (84.13)
		No/not sure	1435	180 (12.54)	418 (29.13)	262 (18.26)	575 (40.07)	74 (5.16)	1361 (94.84)
Vaccination history	I have a history of influenza vaccination.	Yes	268	121 (45.15)	105 (39.18)	19 (7.09)	23 (8.58)	128 (47.76)	140 (52.24)
		No/not sure	1646	153 (9.30)	504 (30.62)	322 (19.56)	667 (40.52)	22 (1.34)	1624 (98.66)
Health services of family physician	I have purchased health services of community family physician.	Yes	1230	187 (15.20)	382 (31.06)	216 (17.56)	445 (36.18)	123 (10.00)	1107 (90.00)
		No/not sure	684	87 (12.72)	227 (33.19)	125 (18.27)	245 (35.82)	27 (3.95)	657 (96.05)

Data are reported as number of participants (%).

Table 4. Demographic characteristics and HBM constructs associated with intention and receipt of 2016–2017 seasonal influenza vaccine among diabetic patients in Ningbo city

		Intention to accept influenza vaccination^a				Receipt of influenza vaccination in 2016/2017^b
Items	Level	COR (95%CI)	p-Value	AOR (95%CI)	p-Value	COR (95%CI)	p-Value	AOR (95%CI)	p-Value
Age		1.01 (1.00–1.02)	0.003	1.00 (0.99–1.01)	0.489	1.03 (1.01–1.05)	0.001	1.04 (1.00–1.08)	0.026
Gender	Male	1.00	-	1.00	-	1.00	-	1.00	-
	Female	0.89 (0.75–1.05)	0.165	0.97 (0.80–1.20)	0.807	0.79 (0.56–1.10)	0.163	1.00 (0.56–1.78)	0.995
Monthly income (CNY)	<3000	1.00	-	1.00	-	1.00	-	1.00	-
	≥3000	0.94 (0.78–1.14)	0.540	0.76 (0.58–1.00)	0.047	1.15 (0.79–1.67)	0.481	0.39 (0.18–0.86)	0.020
Highest level of education attainment	Primary or below	1.00	-	1.00	-	1.00	-	1.00	-
	Secondary	1.11 (0.93–1.32)	0.253	0.84 (0.66–1.07)	0.160	1.09 (0.76–1.56)	0.651	0.56 (0.27–1.16)	0.118
	Tertiary or above	1.45 (0.83–2.53)	0.191	0.71 (0.35–1.45)	0.349	1.75 (0.67–4.57)	0.253	0.37 (0.06–2.29)	0.285
Occupation	Executives and professionals	1.00	-	1.00	-	1.00	-	1.00	-
	Clerks and workers	0.84 (0.58–1.22)	0.359	1.07 (0.69–1.65)	0.766	0.66 (0.37–1.17)	0.156	0.76 (0.27–2.18)	0.617
	Farmers	0.72 (0.51–1.02)	0.063	1.25 (0.79–1.98)	0.340	0.37 (0.21–0.65)	0.001	0.55 (0.17–1.82)	0.329
	Economically inactive	0.95 (0.65–1.39)	0.785	1.23 (0.76–1.99)	0.401	0.38 (0.19–0.73)	0.004	0.57 (0.16–2.00)	0.379
Marital status	Single/divorced/widowed	1.00	-	1.00	-	1.00	-	1.00	-
	Married	0.87 (0.69–1.10)	0.240	0.82 (0.62–1.08)	0.162	1.26 (0.75–2.13)	0.383	1.71 (0.72–4.04)	0.222
Region	Rural	1.00	-	1.00	-	1.00	-	1.00	-
	Urban	1.42 (1.20–1.68)	<0.001	1.02 (0.83–1.25)	0.839	16.84 (7.84–36.16)	<0.001	10.23 (4.01–26.06)	<0.001
Number of Comorbidities^c	0	1.00	-	1.00	-	1.00	-	1.00	-
	1	1.31 (1.09–1.57)	0.003	1.01 (0.82–1.25)	0.891	4.42 (2.55–7.65)	<0.001	4.66 (1.95–11.15)	0.001
	≥2	1.95 (1.47–2.59)	<0.001	1.23 (0.89–1.71)	0.217	4.90 (2.52–9.53)	<0.001	4.49 (1.52–13.22)	0.006
Health Belief Model Constructs
Perceived Susceptibility	Low	1.00	-	1.00	-	1.00	-	1.00	-
	Moderate	1.95 (1.59–2.38)	<0.001	2.09 (1.53–2.85)	<0.001	2.27 (1.48–3.47)	<0.001	3.56 (1.03–12.29)	0.044
	High	3.40 (2.77–4.18)	<0.001	3.57 (2.56–4.99)	<0.001	2.95 (1.96–4.44)	<0.001	4.87 (1.44–16.48)	0.011
Perceived Severity	Low	1.00	-	1.00	-	1.00	-	1.00	-
	Moderate	1.71 (1.39–2.11)	<0.001	2.19 (1.18–4.07)	0.013	1.36 (0.86–2.14)	0.188	0.06 (0.00–1.51)	0.087
	High	2.21 (1.82–2.69)	<0.001	1.50 (0.84–2.68)	0.174	2.12 (1.45–3.09)	<0.001	0.61 (0.04–9.83)	0.725
Perceived Benefits	Low	1.00	-	1.00	-	1.00	-	1.00	-
	Moderate	2.20 (1.82–2.66)	<0.001	1.70 (1.03–2.79)	0.037	5.70 (3.75–8.65)	<0.001	0.55 (0.18–1.67)	0.293
	High	3.52 (2.61–4.76)	<0.001	1.01 (0.09–10.74)	0.996	11.13 (6.86–18.07)	<0.001	14.39 (1.86–111.15)	0.011
Barriers
Unpreventable of influenza	No/not sure	1.00	-	1.00	-	1.00	-	1.00	-
	Yes	0.42 (0.36–0.50)	<0.001	0.80 (0.64–1.00)	0.055	0.07 (0.04–0.14)	<0.001	0.21 (0.08–0.53)	0.001
Safety of vaccine	No/not sure	1.00	-	1.00	-	1.00	-	1.00	-
	Yes	0.67 (0.55–0.80)	<0.001	0.21 (0.11–0.41)	<0.001	0.73 (0.49–1.09)	0.127	0.47 (0.25–0.89)	0.021
Self-efficacy
Payment for vaccine	No/not sure	1.00	-	1.00	-	1.00	-	1.00	-
	Yes	13.25 (10.84–16.20)	<0.001	5.71 (3.95–8.26)	<0.001	5.46 (3.69–8.06)	<0.001	3.61 (1.94–6.71)	<0.001
Accessibility to vaccine	No/not sure	1.00	-	1.00	-	1.00	-	1.00	-
	Yes	3.45 (2.78–4.29)	<0.001	2.66 (1.64–4.32)	<0.001	2.91 (1.63–5.20)	<0.001	0.25 (0.05–1.20)	0.082
Health seeking behaviors	No/not sure	1.00	-	1.00	-	1.00	-	1.00	-
	Yes	1.44 (1.22–1.70)	<0.001	1.21 (1.00–1.46)	0.049	1.61 (1.13–2.29)	0.008	0.76 (0.29–1.96)	0.566
Cues to action
Doctor Recommendation	No/not sure	1.00	-	1.00	-	1.00	-	1.00	-
	Yes	2.78 (2.33–3.31)	<0.001	1.72 (1.36–2.16)	<0.001	6.38 (4.37–9.32)	<0.001	0.38 (0.14–1.03)	0.057
Family/friends influence	No/not sure	1.00	-	1.00	-	1.00	-	1.00	-
	Yes	2.15 (1.71–2.70)	<0.001	1.63 (1.24–2.14)	<0.001	2.18 (1.48–3.19)	<0.001	0.36 (0.09–1.46)	0.152
Media influence	No/not sure	1.00	-	1.00	-	1.00	-	1.00	-
	Yes	1.97 (1.64–2.38)	<0.001	0.78 (0.61–0.99)	0.044	3.47 (2.47–4.87)	<0.001	1.24 (0.66–2.31)	0.498
Vaccination history	No/not sure	1.00	-	1.00	-	1.00	-	1.00	-
	Yes	8.00 (6.17–10.36)	<0.001	3.88 (2.85–5.29)	<0.001	67.49 (41.59–109.53)	<0.001	67.08 (32.74–137.47)	<0.001
Health services of family physician	No/not sure	1.00	-	1.00	-	1.00	-	1.00	-
	Yes	1.04 (0.88–1.23)	0.669	0.24 (0.11–0.54)	0.001	2.70 (1.76–4.15)	<0.001	1.75 (0.89–3.47)	0.106

COR: Crude odds ratio; AOR: Adjusted odds ratio; CI: Confidence interval.

^aCOR and AOR were calculated by binary and multivariate ordered logistic regression models, respectively. In the multivariate ordered logistic regression analysis, the adjusted factors included demographic characteristics, other HBM constructs, and interactions between the HBM items.

^bCOR and AOR were calculated by binary and multivariate logistic regression models, respectively. In the multivariate logistic regression analysis, the adjusted factors included demographic characteristics, other HBM constructs, and interactions between the HBM items.

^cComorbidities included chronic respiratory disease, chronic heart disease, cerebrovascular disease, hypertension, and cancer.

Table 5. Interactions between the HBM items associated with intention and receipt of 2016–2017 seasonal influenza vaccine among diabetic patients in Ningbo city

		Intention to accept influenza vaccination^a		Receipt of influenza vaccination in 2016/2017^b
Items	Level	AOR (95%CI)	p-Value	AOR (95%CI)	p-Value
Perceived Susceptibility*Payment for vaccine	Moderate*Yes	1.88 (1.14–3.11)	0.014	-	-
Perceived Susceptibility*Doctor Recommendation	Moderate*Yes	-	-	4.32 (1.06–17.60)	0.041
Perceived Severity*Perceived Benefits	Moderate*Moderate	-	-	8.08 (1.67–39.14)	0.009
	Moderate*High	13.77 (1.26–149.94)	0.031	-	-
	High* Moderate	0.46 (0.27–0.80)	0.006	13.82 (1.48–129.01)	0.021
Perceived Severity*Accessibility to vaccine	Moderate*Yes	0.39 (0.19–0.83)	0.015	-	-
Perceived Severity* Health seeking behaviors	Moderate*Yes	-	-	10.45 (2.22–49.06)	0.003
Perceived Benefits*Safety of vaccine	Moderate*Yes	3.43 (1.59–7.42)	0.002	-	-
Perceived Benefits*Family/friends influence	Moderate*Yes	-	-	8.89 (1.68–46.98)	0.010
Perceived Benefits*Health services of family physician	Moderate*Yes	4.26 (1.73–10.53)	0.002	-	-

AOR: Adjusted odds ratio; CI: Confidence interval.

^aAOR were calculated by the multivariate ordered logistic regression models, the adjusted factors included demographic characteristics, other HBM constructs, and interactions between the HBM items.

^bAOR were calculated by the multivariate logistic regression model, the adjusted factors included demographic characteristics, other HBM constructs, and interactions between the HBM items.