Influenza vaccination attitudes
and practices among US registered
Sarah J. Clark, MPH,aAnne E. Cowan, MPH,aand Pascale M. Wortley, MD, MPHb
Ann Arbor, Michigan, and Atlanta, Georgia
Background: The influenza vaccination rate among US health care personnel (HCP) remains low and may vary by occupational
categories. The objective of this study was to explore knowledge, attitudes, and beliefs associated with influenza vaccination in
a broad population of registered nurses.
Methods: The study used a cross-sectional mail survey, administered January-March 2006, of 2000 registered nurses in 4 US states.
Results: Of the 2000 surveys sent, 1310 (72%) were returned, and 1017 (67%) were eligible for analysis. The majority of respon-
dents (59%) reported receiving influenza vaccine during the 2005-2006 influenza season. The most common reason for being vac-
cinated was protecting oneself from illness (95%), and the most common reason for not being vaccinated was concern about
adverse reactions (39%). Respondents who reported their patient population as high risk related to influenza were more likely
to be vaccinated and to agree with statements regarding influenza disease and influenza vaccination of HCP.
Conclusion: Concernsaboutadversereactions andvaccineeffectivenesscontinuetobe barrierstoinfluenzavaccinationamongreg-
vaccination rates should include data on vaccine effectiveness and adverse effects, as well as descriptions of high-risk populations.
Key Words: Influenza; vaccination; nurses; survey.
Copyright ª 2009 by the Association for Professionals in Infection Control and Epidemiology, Inc.
(Am J Infect Control 2009;37:551-6.)
Annual influenza vaccination of health care person-
nel (HCP) has been recommended by the US Advisory
Committee on Immunization Practices (ACIP) for
more than 25 years to protect HCP from influenza
and reduce transmission to persons at higher risk for
complications from influenza.1This recommendation
has broad support among many health professional
and other national organizations.2,3However, influenza
vaccination rates have remained substantially below
50% for this target group.1,2,4,5Within the population
of HCP, nurses have been shown to have lower influ-
enza vaccination rates than physicians.6-9
To increase influenza vaccination rates among
nurses, it is important to understand their motivators
and barriers to vaccination. Finding that research
specific to nurses was limited, Willis and Wortley con-
ducted an exploratory study of attitudes and beliefs
associated with influenza vaccination among regis-
tered nurses (RNs) using focus groups in 2 US cities.10
Many focus group participants expressed concerns
about the safety of influenza vaccine and the lack of
information on vaccine effectiveness from year to
year. Vaccinated nurses demonstrated greater knowl-
edge about influenza and risk factors for influenza,
whereas unvaccinated nurses believed they were not
at risk. Both vaccinated and unvaccinated nurses be-
lieved that the rationale for the ACIP recommendation
for HCP to be vaccinated was to protect their own
health and to limit absenteeism. Protecting patients
was infrequently mentioned as a primary reason for
Building off the themes that emerged from the focus
groups, the objective of this study was to explore
knowledge, attitudes, and beliefs (KAB) related to influ-
enza vaccination in a broader population of RNs. The
overall goal was to gather data to inform future inter-
ventions and policies aimed at increasing influenza
vaccination rates among RNs.
of Michigan, Ann Arbor, MIa; and the National Center for Immunization
and Respiratory Diseases, Centers for Disease Control and Prevention,
Address correspondence to Sarah J. Clark, MPH, University of Michi-
gan, 300 N Ingalls Room 6E06, Ann Arbor, MI 48109-5456. E-mail:
Supported by the Centers for Disease Control and Prevention.
The findings and conclusions in this report are those of the authors and
do not necessarily represent the view of the Centers for Disease
Control and Prevention.
Conflicts of interest: None to report.
Copyright ª 2009 by the Association for Professionals in Infection
Control and Epidemiology, Inc.
4. Centers for Disease Control and Prevention. Influenza: self-reported
vaccination coverage trends 1989–2006. Available from: http://www.
July 8, 2008.
5. Walker FJ, Singleton JA, Lu P, Wooten KG, Strikas RA. Influenza
vaccination of healthcare workers in the United States, 1989-2002.
Infect Control Hosp Epidemiol 2006;27:257-65.
6. Christini AB, Shutt KA, Byers KE. Influenza vaccination rates and
motivators among healthcare worker groups. Infect Control Hosp
7. King WD, Woolhandler SJ, Brown AF, Jiang L, Kevorkian K, Himmelstein
DU, et al. Brief report: influenza vaccination and health care workers in
the United States. J Gen Intern Med 2006;21:181-4.
8. Martinello RA, Jones L, Topal JE. Correlation between healthcare
workers’ knowledge of influenza vaccine and vaccine receipt. Infect
Control Hosp Epidemiol 2003;24:845-7.
9. Nichol KL, Hauge M. Influenza vaccination of healthcare workers.
Infect Control Hosp Epidemiol 1997;18:189-94.
10. Willis BC, Wortley P. Nurses’ attitudes and beliefs about influenza and
the influenza vaccine: a summary of focus groups in Alabama and
Michigan. Am J Infect Control 2007;35:20-4.
11. HRSA. The registered nurse population: findings from the March 2004
National Sample Survey of Registered Nurses. June 2006. US DHHS,
HRSA, BHP, Division of Nursing. Available from: http://bhpr.hrsa.gov/
healthworkforce/rnsurvey04/. Accessed July 2, 2008.
12. Cowan AE, Winston CA, Davis MM, Wortley PM, Clark SJ. Influenza
vaccination status and influenza-related perspectives and practices
among US physicians. Am J Infect Control 2006;34:164-9.
13. Centers for Disease Control and Prevention. State-specific influenza
vaccination coverage among adults aged .18 years—United States,
2003-2004 and 2005-2006 influenza seasons. MMWR Morb Mortal
Wkly Rep 2007;56:953-9.
14. McEwen M, Farren E. Actions and beliefs related to hepatitis B and
influenza immunization among registered nurses in Texas. Public
Health Nurs 2005;22:230-9.
15. Ofstead CL, Tucker SJ, Beebe TJ, Poland GA. Influenza vaccination
among registered nurses: information receipt, knowledge, and deci-
sion-making at an institution with a multifaceted educational program.
Infect Control Hosp Epidemiol 2008;29:99-106.
16. Weingarten S, Reidinger M, Bolton LB, Miles P, Ault M. Barriers to
influenza vaccine acceptance: a survey of physicians and nurses. Am
J Infect Control 1989;17:202-7.
17. Joint Commission on the Accreditation of Health Care Organizations.
Approved: new infection control requirement for offering influenza
vaccination to staff and licensed independent practitioners. Jt Comm
Clark, Cowan, and Wortley
American Journal of Infection Control