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The power of anticipated regret: Predictors of HPV vaccination and seasonal influenza vaccination acceptability among young Romanians
Vaccine xxx (xxxx) xxx
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Vaccine journal homepage: www.elsevier.com/locate/vaccine
The power of anticipated regret: Predictors of HPV vaccination and seasonal influenza vaccination acceptability among young Romanians Marcela A. Pentßa a,⇑, Irina Catrinel Cra˘ciun a,b, Adriana Ba˘ban a a b
Babes-Bolyai University, Department of Psychology, 37 Republicii Street, Cluj-Napoca, CJ 400015, Romania Freie Universität Berlin, Habelschwerdter Allee 45, 14195 Berlin, Germany
a r t i c l e
i n f o
Article history: Received 2 June 2019 Received in revised form 27 October 2019 Accepted 11 November 2019 Available online xxxx Keywords: HPV vaccination Seasonal flu vaccination Anticipated regret Health belief model Young adults Romania
a b s t r a c t Background: Understanding lay perceptions concerning vaccination and identifying the most important psychological determinants of vaccine acceptability are relevant for health promotion campaigns. Methods: This cross-sectional study aimed to identify the psychological determinants of HPV vaccine and seasonal flu vaccine acceptability in a national sample of young adults. An extended version of the health belief model (HBM) provided the main theoretical framework. Four hundred and one adults aged 18–26 (79% women), completed the theory-based survey and were included in analyses. The main outcomes were intentions to vaccinate against HPV and the seasonal flu. Descriptive statistics, bivariate correlations and hierarchical multiple regression were used for data analysis. Results: The models predicted 51% and 60% of the variability in intentions to vaccinate against HPV and the seasonal flu, respectively. For both decisional contexts, anticipated inaction regret (assuming one were unvaccinated and later contracted infection) was the strongest predictor of intentions, contributing above and beyond the role of traditional risk belief constructs (HBM constructs). Other shared predictors of intentions were perceived effectiveness of vaccine, perceived vaccine safety, perceived susceptibility to disease and previous vaccine refusal. The study also provides insights into young adults’ vaccine-related knowledge and their information-seeking practices. Conclusion: Findings outline directions for future research and implications for health communication campaigns. Ó 2019 Elsevier Ltd. All rights reserved.
1. Introduction Despite facilitated access and evidence-based recommendations, vaccines remain under-used in many countries, including Romania. In the last decade, there has been an increased interest in the topic of HPV vaccine acceptance [1–8], but few studies were conducted in countries with a very high burden of disease morbidity and mortality, as it is the case with cervical cancer in Romania [8–10]. Whereas researchers stress the need to identify the predictors of vaccine decisions by specific socio-cultural context and type of vaccines [11–13], the lack of research on HPV and other vaccines acceptability constitutes a gap that may hamper future vaccine promotion efforts [1]. The present study addresses this gap and focuses on HPV and seasonal influenza vaccination acceptability among Romanian young adults (18–26-year-old) for several reasons. First, young adults represent a target group for HPV vaccination (‘‘catch-up” ⇑ Corresponding author. E-mail address: [email protected] (M.A. Pentßa).
group), especially as the highest HPV prevalence rates were recorded among the 20-24 age group [14]. Young adults, particularly students, are also at risk for getting and transmitting seasonal influenza [15]. Second, both the HPV and the seasonal influenza vaccines are underutilized by young adults. Romania has the highest cervical cancer mortality in Europe [9] but has extremely low HPV vaccine uptake rates. The uptake of the seasonal flu vaccine among the general population has also been traditionally low [16]. Third, as discussed previously, little is known about determinants of vaccine acceptability among Romanian young adults. There is a need to identify the variables that are predictive of vaccination intention, particularly in an area where trends show low vaccine coverage. Finally, there is no study that comparatively explores predictors of decisions for these two vaccines that entail a contrasting nature of risk perceptions: seasonal flu is common, well-known and contagious, but is usually perceived as mild and unthreatening; HPV is a common sexually transmitted infection, but is less well-known and is likely perceived as threatening (concerns about HPV-related cancer are expected to exceed concerns about the flu).
https://doi.org/10.1016/j.vaccine.2019.11.042 0264-410X/Ó 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: M. A. Pentßa, I. C. Cra˘ciun and A. Ba˘ban, The power of anticipated regret: Predictors of HPV vaccination and seasonal influenza vaccination acceptability among young Romanians, Vaccine, https://doi.org/10.1016/j.vaccine.2019.11.042
2
M.A. Pentßa et al. / Vaccine xxx (xxxx) xxx
With regards to the vaccination background in Romania, in 2008, the Ministry of Health rolled-out a school-based immunization campaign providing free HPV vaccines for 9- to 11-year-old girls, but only 2.57% of the girls were vaccinated [8,17]. In 2009 there was a second vaccination campaign, targeting 12- to 14-year-old girls, but uptake remained low. Later on, adult women were given the opportunity to get free vaccines through their health provider, but the program was discontinued in 2011 when all remaining vaccines expired. No other vaccination campaign has been launched yet and those interested to get vaccinated have to pay for the vaccine out-of-pocket. Notably, a new HPV vaccination campaign targeting 11- to 14-year-old girls whose parents requested the vaccine is set to start in 2020. As to seasonal influenza, an annual vaccination campaign is usually started around October or November, when the vaccine is provided for free for at-risk groups (i.e., elderly persons, people with chronic medical conditions, pregnant women, HCWs, children under 5 years of age) [18]. Non-priority population groups such as healthy young adults who wish to get vaccinated have to pay for the vaccine out-of-pocket. For the present study constructs from an extended version of the health belief model (HBM) [1] provided the main theoretical framework. Traditional cognitive variables (perceived susceptibility, perceived severity, perceived effectiveness, perceived safety or side effects), anticipated emotions (anticipated inaction regret, anticipated worry), cues to action (doctor’s recommendation; having friends who got vaccinated), vaccine-related knowledge and past vaccination behavior were taken into account. Specifically, this study aims to: (1) assess knowledge about the HPV and flu vaccines in a sample of Romanian young adults eligible for vaccination and (2) identify and compare predictors of HPV and flu vaccine acceptability. Results will clarify which theory-driven psychosocial factors are the most relevant predictors of vaccination intentions and identify potential differences in intention predictors among the two distinct vaccination contexts. Based on extensions of the HBM and previous studies [1,19,20], we expected that intentions to vaccinate against HPV and seasonal flu would be positively correlated with: (a) HBM variables: higher perceived susceptibility to disease, higher perceived severity of disease, higher perceived benefits of vaccines, lower perceived side effects, receipt of doctor recommendation and (b) additional variables: higher anticipated inaction regret, higher knowledge about vaccines, pre-existent positive attitudes toward vaccines, no history of vaccine refusal, and higher worry about getting or transmitting the disease to others. Based on emotion-based theories of healthcare decision-making and prior studies [19–22], we hypothesized that anticipated inaction regret would prove more predictive of vaccine acceptability than traditional HBM variables. Overall, theories did not provide strong a priori guidance regarding whether we should expect notable differences concerning the key predictors of intentions across the two types of vaccines. Whereas one reasonable expectation was that anticipated regret would be higher in the HPV context (because HPV-associated cancers or genital warts are likely to be considered more aversive than the flu), the extent to which there would be important differences in the predictive patterns required exploratory study. Lastly, we expected gender to have a larger contribution for HPV vaccine acceptability than for seasonal flu acceptability, considering that the HPV vaccine was marketed only to girls and women in Romania. 2. Methods 2.1. Participants and procedure Data collection took place between September 2014 and August 2015. Participants outside of the targeted age range (outside of 18–
26, n = 27), those with missing values on main variables (n = 5), medical faculty students (n = 5) and those that reported that already got vaccinated (n = 11) were excluded from the analysis, resulting in a final usable sample of 401 participants. All participants signed an informed consent form. Participants completed a pen-and-paper version in regular classroom settings or an online survey (they were recruited through mailing lists). The face-toface (45%) and online (55%) samples were combined for analyses as done in other studies [23]. The final sample of participants was diverse, including students attending various universities and specialties and from several Romanian cities. 2.2. Ethics The study was approved by the ethics committee of the university. 2.3. Measures The survey included measures derived from published scales used in previous vaccine acceptance research [1,20–22,24–32]. Before being applied to the study sample, the survey was pretested with 33 young adults, in order to check for translation adequacy and comprehensibility and was shown to perform well. Notably, as done in previous studies [29], prior to items assessing intentions and other study variables, we have provided participants with brief informative statements about HPV and flu topics, respectively. Previous refusal of a recommended vaccine was assessed with one item (‘‘Yes”/ ‘‘No”/ ‘‘Don’t know” response options). HPV knowledge was assessed with a 16-item scale (Cronbach’s a = 0.92) adapted from past studies [24,27]. Flu and flu-vaccine knowledge was assessed with a 12-item scale (a = 0.78) adapted from past studies [30]. To assess participants’ beliefs about their personal susceptibility to disease, they were asked: ‘‘What is the chance that you will get the seasonal flu [HPV] in the future?” (1 ‘‘no chance” to 5 ‘‘very high”) [24]. Perceived severity of disease was assessed by asking: ‘‘If you became infected with the seasonal flu [HPV], how serious a threat to your health would it be?”(1 ‘‘no threat” to 6 ‘‘very high”) [24]. Anticipated inaction regret assuming one were unvaccinated, and a negative outcome resulted (subsequently contracted infection) was assessed by asking: ‘‘If you became infected with the seasonal flu [HPV], how much would you regret not getting the vaccine?”(1 ‘‘Not at all” to 4 ‘‘Very much”) [20,22,29,31]. Participants’ anticipated worry if they later developed the disease was assessed with: ‘‘If you became infected with the seasonal flu [HPV], how worried would you be?”. Worry about outcomes to others was assessed by asking: ‘‘If you became infected with the seasonal flu [HPV], how worried would you be about infecting other people with the flu [HPV]?[32]. Items were rated on 4-point scales ranging from 1 (‘‘not at all worried”) to 4 (‘‘very worried”). Perceived effectiveness of HPV vaccines was assessed with 2 items: ‘‘How effective do you think the HPV vaccine is in preventing HPV infection [HPV-related cancer]?”(a = 0.82) [27]. Perceived effectiveness of the flu vaccine was assessed with: ‘‘How effective do you think the seasonal flu vaccine is in preventing the flu infection?”(1 ‘‘not at all” to 5 ‘‘very”). Perceived vaccine safety and perceived side effects were assessed with single items: ‘‘The Flu [HPV] vaccine is safe” and ‘‘The flu vaccine [HPV] vaccine can have serious side effects”(1 ‘‘strongly disagree” to 5 ‘‘strongly agree”). Additional items assessed whether the physician recommended the seasonal flu [HPV] vaccine (response options: ‘‘Yes”/‘‘No”/‘‘Do n’t know”) and whether participants have friends, family members or people they know who got vaccinated against the flu [HPV]
Please cite this article as: M. A. Pentßa, I. C. Cra˘ciun and A. Ba˘ban, The power of anticipated regret: Predictors of HPV vaccination and seasonal influenza vaccination acceptability among young Romanians, Vaccine, https://doi.org/10.1016/j.vaccine.2019.11.042
M.A. Pentßa et al. / Vaccine xxx (xxxx) xxx
(‘‘Yes”/ ‘‘No” /‘‘Don’t know”). A battery of questions assessed interest in learning more about vaccines, preferred sources of health information and most trusted information sources [24]. Vaccine acceptability (i.e., intention) was assessed with three items, using a 5-point Likert scale (coded 1–5,” Definitely not” – ‘‘Definitely will”)[28]. Responses to the three items were summed to create a total intention score for the flu vaccine (a = 0.90) and a total intention score for the HPV vaccine (a = 0.87). 2.4. Data analyses We used descriptive statistics to assess vaccine-related acceptability, risk perceptions, and knowledge. Then, we used bivariate correlations (and Point-Biserial correlations) and hierarchic linear regression to identify correlates and predictors of participants’ intentions to get vaccinated. All analyses were performed using SPSS, v 20. 3. Findings 3.1. Characteristics of participants Mean age was 21.49 years (SD = 2.41; range 18–26) and 79% of the sample were women. Almost all participants (95%) were undergraduate or MA students (Table 1). There were no significant differences in socio-demographic variables and intentions between the data collected online and the paper version.
Table 1 Sample characteristics. Variables
n (%)
Age 18–20 21–23 24–26
179 (44.6) 127 (31.6) 95 (23.6)
Sex Female Male
317 (79.1) 84 (20.9)
Relationship status Single Currently in a relationship Married Other/No response
189 (47.1) 175 (43.6) 24 (6.0) 13 (3.2)
Mean (SD) 21.49 (2.41)
3
3.2. Past vaccine refusal Approximately 28% of respondents reported that they had refused at least one routinely recommended vaccine and an additional 9% were uncertain about previous vaccine refusal. 3.3. Information-seeking practices and cues to action When asked about which information source they would most often use for vaccine-related information, 43% of participants answered the Internet/websites, and a similar proportion, 39.7%, listed doctors. By far, doctors represented the most trusted source for vaccine-related information (63.3%), followed by scientific papers (18%) and the Internet (8.5%). Concerning information sources, participants reported using: the Internet (78.3); news articles (64.1%); TV (55%), magazines (47%), radio (39.2%) and newspapers (39.1%). Most participants indicated they would like to receive additional information about the HPV vaccine (79%) and seasonal flu vaccine (75.1%). Few participants reported having received a health care provider recommendation to get the HPV vaccine (3.7%) or seasonal flu vaccine (21.4%). 3.4. HPV and HPV vaccine knowledge About 55% and 46% of the sample reported having heard of HPV and HPV vaccines, respectively. Overall, HPV-related knowledge levels were rather low, with a mean knowledge score of 6.52 (SD = 5.15; maximum score possible was 18). Given that only slightly over half of the sample had heard of HPV, it is relevant to analyze knowledge levels separately, by HPV awareness status. As it can be expected, for participants with no prior awareness the mode was 0, and the mean knowledge score was very low, 2.38. For participants with prior awareness of HPV, the mode was 10 and the mean knowledge score was 9.78, thus indicating moderate knowledge levels. Less than 10% obtained a score of 13 or more. Overall, almost half of the whole sample knew that HPV can cause cervical cancer, but less than a third knew that it can also cause some types of cancer in men. Around 20% falsely believed that condoms provide complete protection against HPV and less than 20% were aware that most sexually active persons are estimated to get HPV at some point in their lifetime, which might contribute to low perceptions of susceptibility to HPV infection. 3.5. Flu and flu vaccine knowledge
Have had at least one sexual experience Yes No
320 (79.8) 69 (17.2)
Previous history of vaccine refusal Yes No/Don’t know
113 (28.2) 288 (71.8)
Ever heard of HPV Yes No/Don’t know
221 (55.1) 173 (43.1)
Ever heard of HPV vaccine Yes No/Don’t know
185 (46.1) 210 (52.3)
Prior HPV diagnosis Yes No/Don’t know
17 (4.2) 377 (94.0)
Provider recommended HPV vaccine Yes No/Don’t know
15 (3.7) 379 (94.5)
Provider recommended Flu vaccine Yes No/Don’t know HPV-related knowledge score (range, 0–18) Flu -related knowledge score (range, 0–12)
86 (21.4) 305 (76.0) 6.52 (5.15) 6.15 (2.29)
Note. N = 401. Totals may not add to 100% due to missing data or rounding.
Overall, flu-related knowledge was moderate, with a mean score of 6.15 (SD = 2.29; maximum score possible was 12), revealing some misconceptions. About 80% of respondents correctly answered that seasonal flu can lead to serious complications. However, only 12.5% knew that more people die from the flu each year than from HIV/AIDS. Around 81% knew that the flu is spread through the air and 58% knew that the flu virus changes every year. Only a third of participants believed that getting the flu shot is a person’s best protection against the flu. Almost 31% believed that the flu vaccine contains a live virus, whereas 27% believed that the flu vaccine can give someone the flu. About 64% knew that following vaccination one might temporary have a sore arm and 14.5% answered ‘‘true” to the statement that the side effects of the flu vaccine are worse than the flu itself. Almost 20% were unsure whether people under the age of 65 should get the flu vaccine. 3.6. Correlations between study variables and vaccination intentions Table 2 presents the bivariate correlations among the flurelated variables of interest. As expected, anticipated inaction
Please cite this article as: M. A. Pentßa, I. C. Cra˘ciun and A. Ba˘ban, The power of anticipated regret: Predictors of HPV vaccination and seasonal influenza vaccination acceptability among young Romanians, Vaccine, https://doi.org/10.1016/j.vaccine.2019.11.042
M.A. Pentßa et al. / Vaccine xxx (xxxx) xxx
4 Table 2 Correlation matrix for the flu vaccine data. Variables
1
2
3
1. 2. 3. 4.
1 0.576** 0.406** 0.346** 0.237**
1 0.512** 0.349** 0.232**
1 0.201** 0.239**
0.204**
0.131**
0.146**
7. Anticipated worry
0.251**
0.158**
0.159**
8. Perceived vaccine effectiveness 9. Perceived vaccine safety 10. Perceived side effects 11. Anticipated regret 12. Worry infecting others 13. Doctor recommendation 14. Have friends who got vaccinated 15. Sex
0.636**
0.623**
0.450**
0.584**
0.661**
0.419**
0.433** 0.663**
0.607** 0.429**
0.285** 0.315**
0.310**
0.265**
0.330**
0.270** -0.050
0.170**
0.056
0.142**
0.158**
0.041
0.007
0.000
Intention Attitudes Knowledge Previous refusal
5. Perceived susceptibility 6. Perceived severity
4
5
6
7
8
9
10
11
12
13
14
15
1 0.141** 0.174** 0.172** 0.279** 0.314** 0.257**
1 0.364**
1
0.175**
0.590**
1
0.234**
0.232**
0.289**
1
0.206**
0.164**
0.208**
0.608**
1
0.118** 0.102*
0.006
-0.011
0.312**
0.408**
0.414** 0.558**
0.595** 0.465**
0.207**
0.413**
0.330**
0.330**
0.340**
-0.010
0.063
0.036
-0.046
0.206**
0.115*
-0.016
0.061
0.021
-0.020
-0.027
-0.064
0.205**
-0.092*
-0.048
1 1
0.085*
0.346** 0.228** -0.024
0.130**
0.090*
0.004
0.090*
0.403**
1
0.127**
0.162**
1
-0.018
0.104*
0.098
0.365**
1
-0.043
0.018
0.013
0.113*
0.024
1
Note. *p < 0.05; **p < 0.01. Previous refusal was coded as 0 = no or don’t know and 1 = yes; Doctor recommendation was coded 0 = no or don’t know and 1 = yes; Have friends who got vaccinated was coded as 0 = no or don’t know and 1 = yes; Sex was coded as 0 = women and 1 = men.
regret, perceived vaccine effectiveness, perceived vaccine safety, perceived side effects, knowledge, previous vaccine refusal, perceived susceptibility and severity of disease, anticipated worry about infection and worry about infecting others were significantly correlated with flu vaccination intentions (all ps < 0.01). In contrast, gender and age were not significant correlates of intention. Table 3 presents the correlations among the HPV-related variables. As expected, anticipated inaction regret, perceived vaccine effectiveness, perceived vaccine safety, perceived side effects, previous refusal, perceived susceptibility, perceived severity, knowledge, anticipated worry, worry about infecting others and whether participants had ever had sex were significantly correlated with HPV vaccination intentions (all ps < 0.01). In addition, gender and sexual history also correlated significantly with HPV vaccination intentions (ps < 0.05). Age was not a significant correlate. Of interest, the correlation between flu vaccination intentions and HPV vaccination intentions was r = 0.66, p < .001. 3.7. Predictors of vaccination intentions The regression models are based on an extended version of the HBM given its proven relevance and importance to vaccine acceptability [1,2]. To explore predictors of intention, two hierarchical multiple regression analyses were performed using HPV vaccination intention (total intention score) and seasonal flu vaccination intention (total score), respectively as the dependent variables (criterion). We first checked for multicollinearity within each of the two models; diagnostics indicated no problematic collinearity within the data as all tolerance values were much above 0.20 and the average variance inflation factor (VIF) was below 1.5. We also conducted the Durbin-Watson test and values were 2.03 for the flu data and 2.01 for the HPV data, suggesting that the assumption of independent errors has been met. Regarding the model predicting flu vaccine acceptability, previous vaccine refusal and vaccine-related knowledge were entered in
the first step of the equation; the HBM-derived variables were added in the second step; followed by anticipated inaction regret in the third step. Anticipated inaction regret (b = 0.42, p < .001), perceived vaccine effectiveness (b = 0.24, p < .001), perceived vaccine safety (b = 0.19, p < .001), previous vaccine refusal (b = 0.10, p < .01) and perceived susceptibility to infection (b = 0.10, p < .01) were significant predictors of flu vaccine acceptability. Overall, the model explained 60% of the variance in behavioral intentions (Table 4). Regarding the model predicting HPV vaccine acceptability, gender and sexual history were entered in the first step of the equation; previous vaccine refusal and HPV-related knowledge were entered in the second step; HBM-derived variables were entered in the third step and anticipated inaction regret in the fourth step. Anticipated inaction regret (b = 0.38, p < .001), perceived vaccine safety (b = 0.22, p < .001), gender (b = -0.17, p < .001), perceived susceptibility to HPV (b = 0.16, p < .001), previous vaccine refusal (b = 0.15, p < .001), perceived vaccine effectiveness (b = 0.13, p < .05) and sexual history (b = 0.09, p < .05) predicted HPV vaccine acceptability. The model explained ~ 51% of the variance in intentions (Table 5). Thus, for both decisional contexts, there was a rather similar pattern of results in that anticipated inaction regret predicted vaccination intentions above and beyond the role of traditional risk beliefs constructs (HBM-derived constructs). Participants who reported higher levels of anticipated regret had higher intentions to vaccinate. Perceived severity of disease did not emerge as a significant predictor in any of the two vaccination contexts. 4. Discussion and conclusion In light of insufficient vaccine coverage, research in the field of psychological factors involved in vaccine acceptability remains timely and meaningful. The present study extends the growing vaccine acceptability literature by investigating the predictors of
Please cite this article as: M. A. Pentßa, I. C. Cra˘ciun and A. Ba˘ban, The power of anticipated regret: Predictors of HPV vaccination and seasonal influenza vaccination acceptability among young Romanians, Vaccine, https://doi.org/10.1016/j.vaccine.2019.11.042
Note. *p < 0.05; **p < 0.01. Previous refusal was coded as 0 = no or don’t know and 1 = yes; Sex was coded as 0 = women and 1 = men; Prior awareness of HPV was coded as 0 = no or don’t know and 1 = yes; Ever had sex was coded as 0 = yes and 1 = no.
1 1 -0.601** 1 -0.074 0.137** 1 0.261** -0.239** 0.364** 1 -0.018 -0.114* -0.047 0.199** 1 -0.021 -0.106 0.066 -0.130* 0.039 1 0.239** 0.048 -0.059 -0.001 -0.004 -0.019 1 -0.271** -0.148 -0.124** -0.030 -0.012 0.096* -0.032 1 -0.480** 0.478** 0.312** 0.075 0.077 0.117* -0.013 0.061 1 0.551** -0.337** 0.579** 0.198** 0.054 -0.004 0.101* -0.022 0.040 1 0.230** 0.145** 0.019 0.236** 0.465** -0.176** -0.118 0.052 0.029 -0.196** 1 0.642** 0.269** 0.145** 0.069 0.197** 0.411** -0.129** -0.083* 0.014 0.012 -0.094* 1 0.046 0.024 0.112* 0.101* -0.042 0.106* 0.222** 0.008 0.028 0.084* -0.225** 0.258** 1 -0.004 -0.086* -0.113* -0.221** -0.215** 0.196** -0.205** -0.075 -0.064 173** 0.030 0.105* -0.035 1 -0.007 0.129* 0.036 0.094* 0.119** 0.116** 0.043 0.049 0.020 -0.162** 0.310** 0.711** -0.132** 0.168** 1 0.498** 0.150** -0.270** 0.254** 0.182** 0.143** 0.527** 0.500** -0.339** 0.592** 0.302** -0.167* -0.002 0.126** -0.143** 0.137* 1. Intention 2. Attitudes 3. Knowledge 4. Previous refusal 5. Perceived susceptibility 6. Perceived severity 7. Anticipated worry 8. Perceived vaccine effectiveness 9. Perceived vaccine safety 10. Perceived side effects 11.Anticipated regret 12. Worry infecting others 13. Sex 14. Age 15. Awareness HPV 16. Ever had sex 17. No. of sexual partners
1 0.204** -0.349** 0.081* 0.099* 0.157** 0.548** 0.566** -0.466** 0.467** 0.266** 0.000 0.167** 0.196** -0.083* 0.056
1 Variables
Table 3 Correlation matrix for the HPV vaccine data.
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
M.A. Pentßa et al. / Vaccine xxx (xxxx) xxx
5
HPV and flu vaccination intentions within a Romanian setting, where statistics showed low uptake rates. To our knowledge, this is the first study to assess predictors for these two different vaccines at one time. This research provides the first information on the theory-based factors that guide acceptability of the HPV vaccine and of the seasonal flu vaccine among a national, non-expert sample of unvaccinated young adults. Our findings indicated the existence of vaccine hesitancy within a significant portion of the sample. Furthermore, the fact that over a quarter of the sample reported having previously refused a routinely recommended vaccine is consistent with current epidemiological reports which indicate suboptimal coverage trends. Guided by an extension of the HBM, the regression models accounted for around 51% and 60% of variance in intentions to vaccinate against HPV and the seasonal flu, respectively. Findings revealed that HPV and seasonal flu vaccine acceptability is driven by an array of psychological factors, out of which the most important is anticipated inaction regret. This finding is consistent with prior studies that found anticipated regret as a key predictor of flu vaccination acceptability [21,31] and of HPV vaccine acceptability among parental samples [20,33,34] and extends this finding to young adults. Other theory-based factors that showed a significant contribution for both vaccination decisions included perceived vaccine effectiveness and safety, perceived susceptibility to disease and past vaccination behavior. Importantly, most of these variables are modifiable and could be targeted in future interventions. The finding that perceived severity of disease is not a significant predictor of intentions is not entirely surprising, given the inconsistent findings in the published literature [1–3]. With respect to knowledge levels and information usage, there are three relevant findings. First, the Internet and online outlets are commonly used for information about vaccines, even though they are not regarded as the most trusted sources. Of note, empirical work has shown that online information, even when it is not considered highly credible, can produce an impact on vaccine risk perceptions [23]. Second, most participants reported that healthcare providers are their best trusted information source. However, only few participants have received a vaccination recommendation from their doctor. This is important considering previous studies that have consistently found that doctor recommendation is a strong predictor of vaccine uptake and acceptability [5– 7,28,35,36]. Thus, one needs to encourage and train health care providers to take a more proactive role regarding vaccinationrelated communication. Of note, a randomized trial found that training doctors to use announcements about vaccination resulted in a clinically meaningful increase in HPV vaccine uptake [37]. Finally, knowledge levels were moderate at best, but most participants (>75%) expressed their interest in learning more about vaccines. Taken together, future information campaigns, if welldesigned and evidence-driven, appear warranted. Efforts should also be made towards informing young men about the utility of HPV vaccination, especially given that this subgroup was largely left out in prior vaccination campaigns. This study has a number of limitations. First, its cross-sectional design which, as opposed to a longitudinal design, precludes us from establishing the causal direction of the observed relationships (given that the variables were assessed concurrently). Second, the study assessed intentions as the outcome variable and not actual vaccination behavior, and we cannot guarantee that intentions translate into action (for a discussion on the ‘‘intention-behavior gap”, see [38]). In fact, this limitation is found in most published studies. Of note, after the national HPV vaccination campaigns were ended, the HPV vaccine was no longer available either in doctors’ offices or in pharmacies, thus it was not possible to measure vaccination behavior. Nonetheless, previous work consistently found intentions to be the strongest and most reliable predictor /
Please cite this article as: M. A. Pentßa, I. C. Cra˘ciun and A. Ba˘ban, The power of anticipated regret: Predictors of HPV vaccination and seasonal influenza vaccination acceptability among young Romanians, Vaccine, https://doi.org/10.1016/j.vaccine.2019.11.042
M.A. Pentßa et al. / Vaccine xxx (xxxx) xxx
6
Table 4 Multiple regression analyses of flu vaccine intention in relation to study variables. Predictor
DR2
Step 1 Previous vaccine refusal (0 = no, 1 = yes) Knowledge
0.24
Step 2 Previous vaccine refusal Knowledge Perceived Susceptibility Perceived Severity Perceived Effectiveness Perceived Safety
0.25
Step 3 Previous vaccine refusal Knowledge Perceived Susceptibility Perceived Severity Perceived Effectiveness Perceived Safety Anticipated inaction regret Total R2 = 0.60 Total Adjusted R2 = 0.595 N = 389
0.11
.
B
SE B
ß
p
2.08 0.53
0.34 0.07
-0.28*** 0.35***
0.000 0.000
0.99 0.12 0.20 0.12 1.53 1.00
0.30 0.06 0.16 0.11 0.19 0.18
-0.13** 0.08 0.05 0.02 0.39*** 0.26***
0.001 0.063 0.209 0.621 0.000 0.000
0.74 0.09 0.39 0.25 0.91 0.72 1.45
0.26 0.05 0.14 0.13 0.18 0.17 0.15
-0.10** 0.06 0.10** 0.07 0.24*** 0.19*** 0.42***
0.005 0.114 0.006 0.052 0.000 0.000 0.000
B
SE B
ß
p value
0.87 1.14
0.38 0.43
-0.11* -0.13**
0.023 0.009
0.88 0.79 1.92 0.07
0.37 0.40 0.33 0.03
-0.12* -0.09 -0.28*** 0.11*
0.019 0.062 0.000 0.031
1.22 0.66 1.10 0.31 0.72 0.08 0.57 1.16
0.31 0.35 0.28 0.24 0.17 0.12 0.09 0.19
6*** -0.08 -0.16*** 0.02 0.17*** 0.01 0.32*** 0.29***
0.000 0.059 0.000 0.659 0.000 0.876 0.000 0.000
1.26 0.74 1.00 0.02 0.68 0.05 0.23 0.90 1.17
0.28 0.32 0.26 0.01 0.16 0.08 0.09 0.18 0.15
-0.17*** -0.09* -0.15*** 0.02 0.16*** 0.01 0.13* 0.22*** 0.38***
. 0.000 0.023 0.000 0.545 0.000 0.923 0.014 0.000 0.000
Table 5 Multiple regression analyses of HPV vaccine intention in relation to study variables. Predictor
DR2
Step 1 Gender (0 = women, 1 = men) Ever had sex (0 = yes, 1 = no)
0.028
Step 2 Gender Ever had sex Previous vaccine refusal (0 = no, 1 = yes) Knowledge
0.087
Step 3 Gender Ever had sex Previous vaccine refusal Knowledge Perceived Susceptibility Perceived Severity Perceived Effectiveness Perceived Safety
0.315
Step 4 Gender Ever had sex Previous vaccine refusal Knowledge Perceived Susceptibility Perceived Severity Perceived Effectiveness Perceived Safety Anticipated inaction regret Total R2 = 0.511 Total Adjusted R2 = 0.500 N = 388
0.081
antecedent of vaccination [21,31], thus we are confident in the relevance of our findings, which extend the existent literature on predictors of vaccine intentions. Third, similar with previous studies [20,33,39,40] for some variables we used single-item measures, but see [21] on arguing that including multiple items does not necessarily provide meaningful benefits: ‘combining individual risk items into multi-item scales did little or nothing to improve predictions and a well-chosen single item can predict just as well as a multi-item scale’. (p.150). Finally, without further research, results cannot be readily generalized to other socio-cultural or
other age groups, as we included a convenience sample of Romanian young adults. In conclusion, this study is the first to examine, in one setting, acceptability of both HPV and seasonal influenza vaccination among young adults. Notwithstanding its limitations, the study contributes to our understanding of young adults’ perspectives on vaccines and points to an array of theory-based factors that appear to guide vaccine-related decisions, offering a starting point to improve health communication. Thus, these findings hold practical implications for crafting more efficacious vaccine promoting
Please cite this article as: M. A. Pentßa, I. C. Cra˘ciun and A. Ba˘ban, The power of anticipated regret: Predictors of HPV vaccination and seasonal influenza vaccination acceptability among young Romanians, Vaccine, https://doi.org/10.1016/j.vaccine.2019.11.042
M.A. Pentßa et al. / Vaccine xxx (xxxx) xxx
interventions and ultimately, for reducing the burden of vaccinepreventable diseases. In terms of theoretical implications, the study adds to recent literature [2,19–22,31] suggesting that health behavior theories used to explain vaccination acceptance should not be based exclusively on traditional risk constructs, but should also incorporate constructs such as anticipated regret. Taken together, there is a continuous need to explore how best to target these theory-based constructs in interventions aimed at reducing vaccine hesitancy and promoting vaccination. In the face of insufficient coverage rates, vaccine risk perception, risk communication and decision-making remain important topics for future research. Without further research, there could be more people who lose confidence in vaccines. Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Acknowledgements We thank Dr. Irina Todorova and the two anonymous reviewers for useful comments on the manuscript. We are also grateful to participants for completing the survey. References [1] Brewer NT, Fazekas KI. Predictors of HPV vaccine acceptability: a theoryinformed, systematic review. Prev Med 2007;45:107–14. https://doi.org/ 10.1016/j.ypmed.2007.05.013. [2] Christy SM, Winger JG, Raffanello EW, Halpern LF, Danoff-Burg S, Mosher CE. The role of anticipated regret and health beliefs in HPV vaccination intentions among young adults. J Behav Med 2016;39:429–40. https://doi.org/10.1007/ s10865-016-9716-z. [3] Donadiki EM, Jimenez-Garcia R, Hernandez-Barrera V, Sourtzi P, CarrascoGarrido P, de Andres Lopez, et al. Health Belief Model applied to noncompliance with HPV vaccine among female university students. Public Health 2014;128:268–73. https://doi.org/10.1016/j.puhe.2013.12.004. [4] Gerend MA, Magloire ZF. Awareness, knowledge, and beliefs about human papillomavirus in a racially diverse sample of young adults. J Adolesc Health 2008;42:237–42. https://doi.org/10.1016/j.jadohealth.2007.08.022. [5] Jones M, Cook R. Intent to receive an HPV vaccine among university men and women and implications for vaccine administration. J Am Coll Health 2008;57:23–32. https://doi.org/10.3200/JACH.57.1.23-32. [6] Krawczyk AL, Perez S, Lau E, Holcroft CA, Amsel R, Knäuper B, et al. Human papillomavirus vaccination intentions and uptake in college women. Health Psychol 2012;31:685–93. https://doi.org/10.1037/a0027012. [7] Rosenthal SL, Weiss TW, Zimet GD, Ma L, Good MB, Vichnin MD. Predictors of HPV vaccine uptake among women aged 19–26: importance of a physician’s recommendation. Vaccine 2011;29:890–5. https://doi.org/10.1016/ j.vaccine.2009.12.063. [8] Craciun C, Ba˘ban A. ‘‘Who will take the blame?”: Understanding the reasons why Romanian mothers decline HPV vaccination for their daughters. Vaccine 2012;30:6789–93. https://doi.org/10.1016/j.vaccine.2012.09.016. [9] World Health Organization [WHO] (2016). European Health for All Database. Retrieved from http://data.euro.who.int/hfadb/. [10] Voida˘zan S, Morariu SH, Tarcea M, Moldovan H, Dobreanu M. Human papilloma virus (HPV) infection and HPV vaccination: assessing the level of knowledge among students of the university of medicine and pharmacy of Tirgu Mures Romania. Acta Dermatovenerol. Croatica 2016;24:193. [11] Larson HJ, Jarrett C, Eckersberger E, Smith DM, Paterson P. Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: a systematic review of published literature, 2007–2012. Vaccine 2014;32:2150–9. https://doi.org/10.1016/j.vaccine.2014.01.081. [12] Betsch C, Böhm R, Airhihenbuwa CO, Butler R, Chapman GB, Haase N, et al. Improving medical decision making and health promotion through culturesensitive health communication: An agenda for science and practice. Med Decis Making 2016;36:811–33. https://doi.org/10.1177/0272989X15600434. [13] MacDonald, N.E. & SAGE Working Group on Vaccine Hesitancy. (2015). Vaccine hesitancy: Definition, scope and determinants. Vaccine, 33, 4161-4164. doi: 10.1016/j.vaccine.2015.04.036. [14] Satterwhite CL, Torrone E, Meites E, Dunne EF, Mahajan R, Ocfemia MCB, et al. Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2008. Sex Transm Dis 2013;40:187–93. https://doi.org/ 10.1097/OLQ.0b013e318286bb53.
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Please cite this article as: M. A. Pentßa, I. C. Cra˘ciun and A. Ba˘ban, The power of anticipated regret: Predictors of HPV vaccination and seasonal influenza vaccination acceptability among young Romanians, Vaccine, https://doi.org/10.1016/j.vaccine.2019.11.042
Contents lists available at ScienceDirect
Vaccine journal homepage: www.elsevier.com/locate/vaccine
The power of anticipated regret: Predictors of HPV vaccination and seasonal influenza vaccination acceptability among young Romanians Marcela A. Pentßa a,⇑, Irina Catrinel Cra˘ciun a,b, Adriana Ba˘ban a a b
Babes-Bolyai University, Department of Psychology, 37 Republicii Street, Cluj-Napoca, CJ 400015, Romania Freie Universität Berlin, Habelschwerdter Allee 45, 14195 Berlin, Germany
a r t i c l e
i n f o
Article history: Received 2 June 2019 Received in revised form 27 October 2019 Accepted 11 November 2019 Available online xxxx Keywords: HPV vaccination Seasonal flu vaccination Anticipated regret Health belief model Young adults Romania
a b s t r a c t Background: Understanding lay perceptions concerning vaccination and identifying the most important psychological determinants of vaccine acceptability are relevant for health promotion campaigns. Methods: This cross-sectional study aimed to identify the psychological determinants of HPV vaccine and seasonal flu vaccine acceptability in a national sample of young adults. An extended version of the health belief model (HBM) provided the main theoretical framework. Four hundred and one adults aged 18–26 (79% women), completed the theory-based survey and were included in analyses. The main outcomes were intentions to vaccinate against HPV and the seasonal flu. Descriptive statistics, bivariate correlations and hierarchical multiple regression were used for data analysis. Results: The models predicted 51% and 60% of the variability in intentions to vaccinate against HPV and the seasonal flu, respectively. For both decisional contexts, anticipated inaction regret (assuming one were unvaccinated and later contracted infection) was the strongest predictor of intentions, contributing above and beyond the role of traditional risk belief constructs (HBM constructs). Other shared predictors of intentions were perceived effectiveness of vaccine, perceived vaccine safety, perceived susceptibility to disease and previous vaccine refusal. The study also provides insights into young adults’ vaccine-related knowledge and their information-seeking practices. Conclusion: Findings outline directions for future research and implications for health communication campaigns. Ó 2019 Elsevier Ltd. All rights reserved.
1. Introduction Despite facilitated access and evidence-based recommendations, vaccines remain under-used in many countries, including Romania. In the last decade, there has been an increased interest in the topic of HPV vaccine acceptance [1–8], but few studies were conducted in countries with a very high burden of disease morbidity and mortality, as it is the case with cervical cancer in Romania [8–10]. Whereas researchers stress the need to identify the predictors of vaccine decisions by specific socio-cultural context and type of vaccines [11–13], the lack of research on HPV and other vaccines acceptability constitutes a gap that may hamper future vaccine promotion efforts [1]. The present study addresses this gap and focuses on HPV and seasonal influenza vaccination acceptability among Romanian young adults (18–26-year-old) for several reasons. First, young adults represent a target group for HPV vaccination (‘‘catch-up” ⇑ Corresponding author. E-mail address: [email protected] (M.A. Pentßa).
group), especially as the highest HPV prevalence rates were recorded among the 20-24 age group [14]. Young adults, particularly students, are also at risk for getting and transmitting seasonal influenza [15]. Second, both the HPV and the seasonal influenza vaccines are underutilized by young adults. Romania has the highest cervical cancer mortality in Europe [9] but has extremely low HPV vaccine uptake rates. The uptake of the seasonal flu vaccine among the general population has also been traditionally low [16]. Third, as discussed previously, little is known about determinants of vaccine acceptability among Romanian young adults. There is a need to identify the variables that are predictive of vaccination intention, particularly in an area where trends show low vaccine coverage. Finally, there is no study that comparatively explores predictors of decisions for these two vaccines that entail a contrasting nature of risk perceptions: seasonal flu is common, well-known and contagious, but is usually perceived as mild and unthreatening; HPV is a common sexually transmitted infection, but is less well-known and is likely perceived as threatening (concerns about HPV-related cancer are expected to exceed concerns about the flu).
https://doi.org/10.1016/j.vaccine.2019.11.042 0264-410X/Ó 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: M. A. Pentßa, I. C. Cra˘ciun and A. Ba˘ban, The power of anticipated regret: Predictors of HPV vaccination and seasonal influenza vaccination acceptability among young Romanians, Vaccine, https://doi.org/10.1016/j.vaccine.2019.11.042
2
M.A. Pentßa et al. / Vaccine xxx (xxxx) xxx
With regards to the vaccination background in Romania, in 2008, the Ministry of Health rolled-out a school-based immunization campaign providing free HPV vaccines for 9- to 11-year-old girls, but only 2.57% of the girls were vaccinated [8,17]. In 2009 there was a second vaccination campaign, targeting 12- to 14-year-old girls, but uptake remained low. Later on, adult women were given the opportunity to get free vaccines through their health provider, but the program was discontinued in 2011 when all remaining vaccines expired. No other vaccination campaign has been launched yet and those interested to get vaccinated have to pay for the vaccine out-of-pocket. Notably, a new HPV vaccination campaign targeting 11- to 14-year-old girls whose parents requested the vaccine is set to start in 2020. As to seasonal influenza, an annual vaccination campaign is usually started around October or November, when the vaccine is provided for free for at-risk groups (i.e., elderly persons, people with chronic medical conditions, pregnant women, HCWs, children under 5 years of age) [18]. Non-priority population groups such as healthy young adults who wish to get vaccinated have to pay for the vaccine out-of-pocket. For the present study constructs from an extended version of the health belief model (HBM) [1] provided the main theoretical framework. Traditional cognitive variables (perceived susceptibility, perceived severity, perceived effectiveness, perceived safety or side effects), anticipated emotions (anticipated inaction regret, anticipated worry), cues to action (doctor’s recommendation; having friends who got vaccinated), vaccine-related knowledge and past vaccination behavior were taken into account. Specifically, this study aims to: (1) assess knowledge about the HPV and flu vaccines in a sample of Romanian young adults eligible for vaccination and (2) identify and compare predictors of HPV and flu vaccine acceptability. Results will clarify which theory-driven psychosocial factors are the most relevant predictors of vaccination intentions and identify potential differences in intention predictors among the two distinct vaccination contexts. Based on extensions of the HBM and previous studies [1,19,20], we expected that intentions to vaccinate against HPV and seasonal flu would be positively correlated with: (a) HBM variables: higher perceived susceptibility to disease, higher perceived severity of disease, higher perceived benefits of vaccines, lower perceived side effects, receipt of doctor recommendation and (b) additional variables: higher anticipated inaction regret, higher knowledge about vaccines, pre-existent positive attitudes toward vaccines, no history of vaccine refusal, and higher worry about getting or transmitting the disease to others. Based on emotion-based theories of healthcare decision-making and prior studies [19–22], we hypothesized that anticipated inaction regret would prove more predictive of vaccine acceptability than traditional HBM variables. Overall, theories did not provide strong a priori guidance regarding whether we should expect notable differences concerning the key predictors of intentions across the two types of vaccines. Whereas one reasonable expectation was that anticipated regret would be higher in the HPV context (because HPV-associated cancers or genital warts are likely to be considered more aversive than the flu), the extent to which there would be important differences in the predictive patterns required exploratory study. Lastly, we expected gender to have a larger contribution for HPV vaccine acceptability than for seasonal flu acceptability, considering that the HPV vaccine was marketed only to girls and women in Romania. 2. Methods 2.1. Participants and procedure Data collection took place between September 2014 and August 2015. Participants outside of the targeted age range (outside of 18–
26, n = 27), those with missing values on main variables (n = 5), medical faculty students (n = 5) and those that reported that already got vaccinated (n = 11) were excluded from the analysis, resulting in a final usable sample of 401 participants. All participants signed an informed consent form. Participants completed a pen-and-paper version in regular classroom settings or an online survey (they were recruited through mailing lists). The face-toface (45%) and online (55%) samples were combined for analyses as done in other studies [23]. The final sample of participants was diverse, including students attending various universities and specialties and from several Romanian cities. 2.2. Ethics The study was approved by the ethics committee of the university. 2.3. Measures The survey included measures derived from published scales used in previous vaccine acceptance research [1,20–22,24–32]. Before being applied to the study sample, the survey was pretested with 33 young adults, in order to check for translation adequacy and comprehensibility and was shown to perform well. Notably, as done in previous studies [29], prior to items assessing intentions and other study variables, we have provided participants with brief informative statements about HPV and flu topics, respectively. Previous refusal of a recommended vaccine was assessed with one item (‘‘Yes”/ ‘‘No”/ ‘‘Don’t know” response options). HPV knowledge was assessed with a 16-item scale (Cronbach’s a = 0.92) adapted from past studies [24,27]. Flu and flu-vaccine knowledge was assessed with a 12-item scale (a = 0.78) adapted from past studies [30]. To assess participants’ beliefs about their personal susceptibility to disease, they were asked: ‘‘What is the chance that you will get the seasonal flu [HPV] in the future?” (1 ‘‘no chance” to 5 ‘‘very high”) [24]. Perceived severity of disease was assessed by asking: ‘‘If you became infected with the seasonal flu [HPV], how serious a threat to your health would it be?”(1 ‘‘no threat” to 6 ‘‘very high”) [24]. Anticipated inaction regret assuming one were unvaccinated, and a negative outcome resulted (subsequently contracted infection) was assessed by asking: ‘‘If you became infected with the seasonal flu [HPV], how much would you regret not getting the vaccine?”(1 ‘‘Not at all” to 4 ‘‘Very much”) [20,22,29,31]. Participants’ anticipated worry if they later developed the disease was assessed with: ‘‘If you became infected with the seasonal flu [HPV], how worried would you be?”. Worry about outcomes to others was assessed by asking: ‘‘If you became infected with the seasonal flu [HPV], how worried would you be about infecting other people with the flu [HPV]?[32]. Items were rated on 4-point scales ranging from 1 (‘‘not at all worried”) to 4 (‘‘very worried”). Perceived effectiveness of HPV vaccines was assessed with 2 items: ‘‘How effective do you think the HPV vaccine is in preventing HPV infection [HPV-related cancer]?”(a = 0.82) [27]. Perceived effectiveness of the flu vaccine was assessed with: ‘‘How effective do you think the seasonal flu vaccine is in preventing the flu infection?”(1 ‘‘not at all” to 5 ‘‘very”). Perceived vaccine safety and perceived side effects were assessed with single items: ‘‘The Flu [HPV] vaccine is safe” and ‘‘The flu vaccine [HPV] vaccine can have serious side effects”(1 ‘‘strongly disagree” to 5 ‘‘strongly agree”). Additional items assessed whether the physician recommended the seasonal flu [HPV] vaccine (response options: ‘‘Yes”/‘‘No”/‘‘Do n’t know”) and whether participants have friends, family members or people they know who got vaccinated against the flu [HPV]
Please cite this article as: M. A. Pentßa, I. C. Cra˘ciun and A. Ba˘ban, The power of anticipated regret: Predictors of HPV vaccination and seasonal influenza vaccination acceptability among young Romanians, Vaccine, https://doi.org/10.1016/j.vaccine.2019.11.042
M.A. Pentßa et al. / Vaccine xxx (xxxx) xxx
(‘‘Yes”/ ‘‘No” /‘‘Don’t know”). A battery of questions assessed interest in learning more about vaccines, preferred sources of health information and most trusted information sources [24]. Vaccine acceptability (i.e., intention) was assessed with three items, using a 5-point Likert scale (coded 1–5,” Definitely not” – ‘‘Definitely will”)[28]. Responses to the three items were summed to create a total intention score for the flu vaccine (a = 0.90) and a total intention score for the HPV vaccine (a = 0.87). 2.4. Data analyses We used descriptive statistics to assess vaccine-related acceptability, risk perceptions, and knowledge. Then, we used bivariate correlations (and Point-Biserial correlations) and hierarchic linear regression to identify correlates and predictors of participants’ intentions to get vaccinated. All analyses were performed using SPSS, v 20. 3. Findings 3.1. Characteristics of participants Mean age was 21.49 years (SD = 2.41; range 18–26) and 79% of the sample were women. Almost all participants (95%) were undergraduate or MA students (Table 1). There were no significant differences in socio-demographic variables and intentions between the data collected online and the paper version.
Table 1 Sample characteristics. Variables
n (%)
Age 18–20 21–23 24–26
179 (44.6) 127 (31.6) 95 (23.6)
Sex Female Male
317 (79.1) 84 (20.9)
Relationship status Single Currently in a relationship Married Other/No response
189 (47.1) 175 (43.6) 24 (6.0) 13 (3.2)
Mean (SD) 21.49 (2.41)
3
3.2. Past vaccine refusal Approximately 28% of respondents reported that they had refused at least one routinely recommended vaccine and an additional 9% were uncertain about previous vaccine refusal. 3.3. Information-seeking practices and cues to action When asked about which information source they would most often use for vaccine-related information, 43% of participants answered the Internet/websites, and a similar proportion, 39.7%, listed doctors. By far, doctors represented the most trusted source for vaccine-related information (63.3%), followed by scientific papers (18%) and the Internet (8.5%). Concerning information sources, participants reported using: the Internet (78.3); news articles (64.1%); TV (55%), magazines (47%), radio (39.2%) and newspapers (39.1%). Most participants indicated they would like to receive additional information about the HPV vaccine (79%) and seasonal flu vaccine (75.1%). Few participants reported having received a health care provider recommendation to get the HPV vaccine (3.7%) or seasonal flu vaccine (21.4%). 3.4. HPV and HPV vaccine knowledge About 55% and 46% of the sample reported having heard of HPV and HPV vaccines, respectively. Overall, HPV-related knowledge levels were rather low, with a mean knowledge score of 6.52 (SD = 5.15; maximum score possible was 18). Given that only slightly over half of the sample had heard of HPV, it is relevant to analyze knowledge levels separately, by HPV awareness status. As it can be expected, for participants with no prior awareness the mode was 0, and the mean knowledge score was very low, 2.38. For participants with prior awareness of HPV, the mode was 10 and the mean knowledge score was 9.78, thus indicating moderate knowledge levels. Less than 10% obtained a score of 13 or more. Overall, almost half of the whole sample knew that HPV can cause cervical cancer, but less than a third knew that it can also cause some types of cancer in men. Around 20% falsely believed that condoms provide complete protection against HPV and less than 20% were aware that most sexually active persons are estimated to get HPV at some point in their lifetime, which might contribute to low perceptions of susceptibility to HPV infection. 3.5. Flu and flu vaccine knowledge
Have had at least one sexual experience Yes No
320 (79.8) 69 (17.2)
Previous history of vaccine refusal Yes No/Don’t know
113 (28.2) 288 (71.8)
Ever heard of HPV Yes No/Don’t know
221 (55.1) 173 (43.1)
Ever heard of HPV vaccine Yes No/Don’t know
185 (46.1) 210 (52.3)
Prior HPV diagnosis Yes No/Don’t know
17 (4.2) 377 (94.0)
Provider recommended HPV vaccine Yes No/Don’t know
15 (3.7) 379 (94.5)
Provider recommended Flu vaccine Yes No/Don’t know HPV-related knowledge score (range, 0–18) Flu -related knowledge score (range, 0–12)
86 (21.4) 305 (76.0) 6.52 (5.15) 6.15 (2.29)
Note. N = 401. Totals may not add to 100% due to missing data or rounding.
Overall, flu-related knowledge was moderate, with a mean score of 6.15 (SD = 2.29; maximum score possible was 12), revealing some misconceptions. About 80% of respondents correctly answered that seasonal flu can lead to serious complications. However, only 12.5% knew that more people die from the flu each year than from HIV/AIDS. Around 81% knew that the flu is spread through the air and 58% knew that the flu virus changes every year. Only a third of participants believed that getting the flu shot is a person’s best protection against the flu. Almost 31% believed that the flu vaccine contains a live virus, whereas 27% believed that the flu vaccine can give someone the flu. About 64% knew that following vaccination one might temporary have a sore arm and 14.5% answered ‘‘true” to the statement that the side effects of the flu vaccine are worse than the flu itself. Almost 20% were unsure whether people under the age of 65 should get the flu vaccine. 3.6. Correlations between study variables and vaccination intentions Table 2 presents the bivariate correlations among the flurelated variables of interest. As expected, anticipated inaction
Please cite this article as: M. A. Pentßa, I. C. Cra˘ciun and A. Ba˘ban, The power of anticipated regret: Predictors of HPV vaccination and seasonal influenza vaccination acceptability among young Romanians, Vaccine, https://doi.org/10.1016/j.vaccine.2019.11.042
M.A. Pentßa et al. / Vaccine xxx (xxxx) xxx
4 Table 2 Correlation matrix for the flu vaccine data. Variables
1
2
3
1. 2. 3. 4.
1 0.576** 0.406** 0.346** 0.237**
1 0.512** 0.349** 0.232**
1 0.201** 0.239**
0.204**
0.131**
0.146**
7. Anticipated worry
0.251**
0.158**
0.159**
8. Perceived vaccine effectiveness 9. Perceived vaccine safety 10. Perceived side effects 11. Anticipated regret 12. Worry infecting others 13. Doctor recommendation 14. Have friends who got vaccinated 15. Sex
0.636**
0.623**
0.450**
0.584**
0.661**
0.419**
0.433** 0.663**
0.607** 0.429**
0.285** 0.315**
0.310**
0.265**
0.330**
0.270** -0.050
0.170**
0.056
0.142**
0.158**
0.041
0.007
0.000
Intention Attitudes Knowledge Previous refusal
5. Perceived susceptibility 6. Perceived severity
4
5
6
7
8
9
10
11
12
13
14
15
1 0.141** 0.174** 0.172** 0.279** 0.314** 0.257**
1 0.364**
1
0.175**
0.590**
1
0.234**
0.232**
0.289**
1
0.206**
0.164**
0.208**
0.608**
1
0.118** 0.102*
0.006
-0.011
0.312**
0.408**
0.414** 0.558**
0.595** 0.465**
0.207**
0.413**
0.330**
0.330**
0.340**
-0.010
0.063
0.036
-0.046
0.206**
0.115*
-0.016
0.061
0.021
-0.020
-0.027
-0.064
0.205**
-0.092*
-0.048
1 1
0.085*
0.346** 0.228** -0.024
0.130**
0.090*
0.004
0.090*
0.403**
1
0.127**
0.162**
1
-0.018
0.104*
0.098
0.365**
1
-0.043
0.018
0.013
0.113*
0.024
1
Note. *p < 0.05; **p < 0.01. Previous refusal was coded as 0 = no or don’t know and 1 = yes; Doctor recommendation was coded 0 = no or don’t know and 1 = yes; Have friends who got vaccinated was coded as 0 = no or don’t know and 1 = yes; Sex was coded as 0 = women and 1 = men.
regret, perceived vaccine effectiveness, perceived vaccine safety, perceived side effects, knowledge, previous vaccine refusal, perceived susceptibility and severity of disease, anticipated worry about infection and worry about infecting others were significantly correlated with flu vaccination intentions (all ps < 0.01). In contrast, gender and age were not significant correlates of intention. Table 3 presents the correlations among the HPV-related variables. As expected, anticipated inaction regret, perceived vaccine effectiveness, perceived vaccine safety, perceived side effects, previous refusal, perceived susceptibility, perceived severity, knowledge, anticipated worry, worry about infecting others and whether participants had ever had sex were significantly correlated with HPV vaccination intentions (all ps < 0.01). In addition, gender and sexual history also correlated significantly with HPV vaccination intentions (ps < 0.05). Age was not a significant correlate. Of interest, the correlation between flu vaccination intentions and HPV vaccination intentions was r = 0.66, p < .001. 3.7. Predictors of vaccination intentions The regression models are based on an extended version of the HBM given its proven relevance and importance to vaccine acceptability [1,2]. To explore predictors of intention, two hierarchical multiple regression analyses were performed using HPV vaccination intention (total intention score) and seasonal flu vaccination intention (total score), respectively as the dependent variables (criterion). We first checked for multicollinearity within each of the two models; diagnostics indicated no problematic collinearity within the data as all tolerance values were much above 0.20 and the average variance inflation factor (VIF) was below 1.5. We also conducted the Durbin-Watson test and values were 2.03 for the flu data and 2.01 for the HPV data, suggesting that the assumption of independent errors has been met. Regarding the model predicting flu vaccine acceptability, previous vaccine refusal and vaccine-related knowledge were entered in
the first step of the equation; the HBM-derived variables were added in the second step; followed by anticipated inaction regret in the third step. Anticipated inaction regret (b = 0.42, p < .001), perceived vaccine effectiveness (b = 0.24, p < .001), perceived vaccine safety (b = 0.19, p < .001), previous vaccine refusal (b = 0.10, p < .01) and perceived susceptibility to infection (b = 0.10, p < .01) were significant predictors of flu vaccine acceptability. Overall, the model explained 60% of the variance in behavioral intentions (Table 4). Regarding the model predicting HPV vaccine acceptability, gender and sexual history were entered in the first step of the equation; previous vaccine refusal and HPV-related knowledge were entered in the second step; HBM-derived variables were entered in the third step and anticipated inaction regret in the fourth step. Anticipated inaction regret (b = 0.38, p < .001), perceived vaccine safety (b = 0.22, p < .001), gender (b = -0.17, p < .001), perceived susceptibility to HPV (b = 0.16, p < .001), previous vaccine refusal (b = 0.15, p < .001), perceived vaccine effectiveness (b = 0.13, p < .05) and sexual history (b = 0.09, p < .05) predicted HPV vaccine acceptability. The model explained ~ 51% of the variance in intentions (Table 5). Thus, for both decisional contexts, there was a rather similar pattern of results in that anticipated inaction regret predicted vaccination intentions above and beyond the role of traditional risk beliefs constructs (HBM-derived constructs). Participants who reported higher levels of anticipated regret had higher intentions to vaccinate. Perceived severity of disease did not emerge as a significant predictor in any of the two vaccination contexts. 4. Discussion and conclusion In light of insufficient vaccine coverage, research in the field of psychological factors involved in vaccine acceptability remains timely and meaningful. The present study extends the growing vaccine acceptability literature by investigating the predictors of
Please cite this article as: M. A. Pentßa, I. C. Cra˘ciun and A. Ba˘ban, The power of anticipated regret: Predictors of HPV vaccination and seasonal influenza vaccination acceptability among young Romanians, Vaccine, https://doi.org/10.1016/j.vaccine.2019.11.042
Note. *p < 0.05; **p < 0.01. Previous refusal was coded as 0 = no or don’t know and 1 = yes; Sex was coded as 0 = women and 1 = men; Prior awareness of HPV was coded as 0 = no or don’t know and 1 = yes; Ever had sex was coded as 0 = yes and 1 = no.
1 1 -0.601** 1 -0.074 0.137** 1 0.261** -0.239** 0.364** 1 -0.018 -0.114* -0.047 0.199** 1 -0.021 -0.106 0.066 -0.130* 0.039 1 0.239** 0.048 -0.059 -0.001 -0.004 -0.019 1 -0.271** -0.148 -0.124** -0.030 -0.012 0.096* -0.032 1 -0.480** 0.478** 0.312** 0.075 0.077 0.117* -0.013 0.061 1 0.551** -0.337** 0.579** 0.198** 0.054 -0.004 0.101* -0.022 0.040 1 0.230** 0.145** 0.019 0.236** 0.465** -0.176** -0.118 0.052 0.029 -0.196** 1 0.642** 0.269** 0.145** 0.069 0.197** 0.411** -0.129** -0.083* 0.014 0.012 -0.094* 1 0.046 0.024 0.112* 0.101* -0.042 0.106* 0.222** 0.008 0.028 0.084* -0.225** 0.258** 1 -0.004 -0.086* -0.113* -0.221** -0.215** 0.196** -0.205** -0.075 -0.064 173** 0.030 0.105* -0.035 1 -0.007 0.129* 0.036 0.094* 0.119** 0.116** 0.043 0.049 0.020 -0.162** 0.310** 0.711** -0.132** 0.168** 1 0.498** 0.150** -0.270** 0.254** 0.182** 0.143** 0.527** 0.500** -0.339** 0.592** 0.302** -0.167* -0.002 0.126** -0.143** 0.137* 1. Intention 2. Attitudes 3. Knowledge 4. Previous refusal 5. Perceived susceptibility 6. Perceived severity 7. Anticipated worry 8. Perceived vaccine effectiveness 9. Perceived vaccine safety 10. Perceived side effects 11.Anticipated regret 12. Worry infecting others 13. Sex 14. Age 15. Awareness HPV 16. Ever had sex 17. No. of sexual partners
1 0.204** -0.349** 0.081* 0.099* 0.157** 0.548** 0.566** -0.466** 0.467** 0.266** 0.000 0.167** 0.196** -0.083* 0.056
1 Variables
Table 3 Correlation matrix for the HPV vaccine data.
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
M.A. Pentßa et al. / Vaccine xxx (xxxx) xxx
5
HPV and flu vaccination intentions within a Romanian setting, where statistics showed low uptake rates. To our knowledge, this is the first study to assess predictors for these two different vaccines at one time. This research provides the first information on the theory-based factors that guide acceptability of the HPV vaccine and of the seasonal flu vaccine among a national, non-expert sample of unvaccinated young adults. Our findings indicated the existence of vaccine hesitancy within a significant portion of the sample. Furthermore, the fact that over a quarter of the sample reported having previously refused a routinely recommended vaccine is consistent with current epidemiological reports which indicate suboptimal coverage trends. Guided by an extension of the HBM, the regression models accounted for around 51% and 60% of variance in intentions to vaccinate against HPV and the seasonal flu, respectively. Findings revealed that HPV and seasonal flu vaccine acceptability is driven by an array of psychological factors, out of which the most important is anticipated inaction regret. This finding is consistent with prior studies that found anticipated regret as a key predictor of flu vaccination acceptability [21,31] and of HPV vaccine acceptability among parental samples [20,33,34] and extends this finding to young adults. Other theory-based factors that showed a significant contribution for both vaccination decisions included perceived vaccine effectiveness and safety, perceived susceptibility to disease and past vaccination behavior. Importantly, most of these variables are modifiable and could be targeted in future interventions. The finding that perceived severity of disease is not a significant predictor of intentions is not entirely surprising, given the inconsistent findings in the published literature [1–3]. With respect to knowledge levels and information usage, there are three relevant findings. First, the Internet and online outlets are commonly used for information about vaccines, even though they are not regarded as the most trusted sources. Of note, empirical work has shown that online information, even when it is not considered highly credible, can produce an impact on vaccine risk perceptions [23]. Second, most participants reported that healthcare providers are their best trusted information source. However, only few participants have received a vaccination recommendation from their doctor. This is important considering previous studies that have consistently found that doctor recommendation is a strong predictor of vaccine uptake and acceptability [5– 7,28,35,36]. Thus, one needs to encourage and train health care providers to take a more proactive role regarding vaccinationrelated communication. Of note, a randomized trial found that training doctors to use announcements about vaccination resulted in a clinically meaningful increase in HPV vaccine uptake [37]. Finally, knowledge levels were moderate at best, but most participants (>75%) expressed their interest in learning more about vaccines. Taken together, future information campaigns, if welldesigned and evidence-driven, appear warranted. Efforts should also be made towards informing young men about the utility of HPV vaccination, especially given that this subgroup was largely left out in prior vaccination campaigns. This study has a number of limitations. First, its cross-sectional design which, as opposed to a longitudinal design, precludes us from establishing the causal direction of the observed relationships (given that the variables were assessed concurrently). Second, the study assessed intentions as the outcome variable and not actual vaccination behavior, and we cannot guarantee that intentions translate into action (for a discussion on the ‘‘intention-behavior gap”, see [38]). In fact, this limitation is found in most published studies. Of note, after the national HPV vaccination campaigns were ended, the HPV vaccine was no longer available either in doctors’ offices or in pharmacies, thus it was not possible to measure vaccination behavior. Nonetheless, previous work consistently found intentions to be the strongest and most reliable predictor /
Please cite this article as: M. A. Pentßa, I. C. Cra˘ciun and A. Ba˘ban, The power of anticipated regret: Predictors of HPV vaccination and seasonal influenza vaccination acceptability among young Romanians, Vaccine, https://doi.org/10.1016/j.vaccine.2019.11.042
M.A. Pentßa et al. / Vaccine xxx (xxxx) xxx
6
Table 4 Multiple regression analyses of flu vaccine intention in relation to study variables. Predictor
DR2
Step 1 Previous vaccine refusal (0 = no, 1 = yes) Knowledge
0.24
Step 2 Previous vaccine refusal Knowledge Perceived Susceptibility Perceived Severity Perceived Effectiveness Perceived Safety
0.25
Step 3 Previous vaccine refusal Knowledge Perceived Susceptibility Perceived Severity Perceived Effectiveness Perceived Safety Anticipated inaction regret Total R2 = 0.60 Total Adjusted R2 = 0.595 N = 389
0.11
.
B
SE B
ß
p
2.08 0.53
0.34 0.07
-0.28*** 0.35***
0.000 0.000
0.99 0.12 0.20 0.12 1.53 1.00
0.30 0.06 0.16 0.11 0.19 0.18
-0.13** 0.08 0.05 0.02 0.39*** 0.26***
0.001 0.063 0.209 0.621 0.000 0.000
0.74 0.09 0.39 0.25 0.91 0.72 1.45
0.26 0.05 0.14 0.13 0.18 0.17 0.15
-0.10** 0.06 0.10** 0.07 0.24*** 0.19*** 0.42***
0.005 0.114 0.006 0.052 0.000 0.000 0.000
B
SE B
ß
p value
0.87 1.14
0.38 0.43
-0.11* -0.13**
0.023 0.009
0.88 0.79 1.92 0.07
0.37 0.40 0.33 0.03
-0.12* -0.09 -0.28*** 0.11*
0.019 0.062 0.000 0.031
1.22 0.66 1.10 0.31 0.72 0.08 0.57 1.16
0.31 0.35 0.28 0.24 0.17 0.12 0.09 0.19
6*** -0.08 -0.16*** 0.02 0.17*** 0.01 0.32*** 0.29***
0.000 0.059 0.000 0.659 0.000 0.876 0.000 0.000
1.26 0.74 1.00 0.02 0.68 0.05 0.23 0.90 1.17
0.28 0.32 0.26 0.01 0.16 0.08 0.09 0.18 0.15
-0.17*** -0.09* -0.15*** 0.02 0.16*** 0.01 0.13* 0.22*** 0.38***
. 0.000 0.023 0.000 0.545 0.000 0.923 0.014 0.000 0.000
Table 5 Multiple regression analyses of HPV vaccine intention in relation to study variables. Predictor
DR2
Step 1 Gender (0 = women, 1 = men) Ever had sex (0 = yes, 1 = no)
0.028
Step 2 Gender Ever had sex Previous vaccine refusal (0 = no, 1 = yes) Knowledge
0.087
Step 3 Gender Ever had sex Previous vaccine refusal Knowledge Perceived Susceptibility Perceived Severity Perceived Effectiveness Perceived Safety
0.315
Step 4 Gender Ever had sex Previous vaccine refusal Knowledge Perceived Susceptibility Perceived Severity Perceived Effectiveness Perceived Safety Anticipated inaction regret Total R2 = 0.511 Total Adjusted R2 = 0.500 N = 388
0.081
antecedent of vaccination [21,31], thus we are confident in the relevance of our findings, which extend the existent literature on predictors of vaccine intentions. Third, similar with previous studies [20,33,39,40] for some variables we used single-item measures, but see [21] on arguing that including multiple items does not necessarily provide meaningful benefits: ‘combining individual risk items into multi-item scales did little or nothing to improve predictions and a well-chosen single item can predict just as well as a multi-item scale’. (p.150). Finally, without further research, results cannot be readily generalized to other socio-cultural or
other age groups, as we included a convenience sample of Romanian young adults. In conclusion, this study is the first to examine, in one setting, acceptability of both HPV and seasonal influenza vaccination among young adults. Notwithstanding its limitations, the study contributes to our understanding of young adults’ perspectives on vaccines and points to an array of theory-based factors that appear to guide vaccine-related decisions, offering a starting point to improve health communication. Thus, these findings hold practical implications for crafting more efficacious vaccine promoting
Please cite this article as: M. A. Pentßa, I. C. Cra˘ciun and A. Ba˘ban, The power of anticipated regret: Predictors of HPV vaccination and seasonal influenza vaccination acceptability among young Romanians, Vaccine, https://doi.org/10.1016/j.vaccine.2019.11.042
M.A. Pentßa et al. / Vaccine xxx (xxxx) xxx
interventions and ultimately, for reducing the burden of vaccinepreventable diseases. In terms of theoretical implications, the study adds to recent literature [2,19–22,31] suggesting that health behavior theories used to explain vaccination acceptance should not be based exclusively on traditional risk constructs, but should also incorporate constructs such as anticipated regret. Taken together, there is a continuous need to explore how best to target these theory-based constructs in interventions aimed at reducing vaccine hesitancy and promoting vaccination. In the face of insufficient coverage rates, vaccine risk perception, risk communication and decision-making remain important topics for future research. Without further research, there could be more people who lose confidence in vaccines. Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Acknowledgements We thank Dr. Irina Todorova and the two anonymous reviewers for useful comments on the manuscript. We are also grateful to participants for completing the survey. References [1] Brewer NT, Fazekas KI. Predictors of HPV vaccine acceptability: a theoryinformed, systematic review. Prev Med 2007;45:107–14. https://doi.org/ 10.1016/j.ypmed.2007.05.013. [2] Christy SM, Winger JG, Raffanello EW, Halpern LF, Danoff-Burg S, Mosher CE. The role of anticipated regret and health beliefs in HPV vaccination intentions among young adults. J Behav Med 2016;39:429–40. https://doi.org/10.1007/ s10865-016-9716-z. [3] Donadiki EM, Jimenez-Garcia R, Hernandez-Barrera V, Sourtzi P, CarrascoGarrido P, de Andres Lopez, et al. Health Belief Model applied to noncompliance with HPV vaccine among female university students. Public Health 2014;128:268–73. https://doi.org/10.1016/j.puhe.2013.12.004. [4] Gerend MA, Magloire ZF. Awareness, knowledge, and beliefs about human papillomavirus in a racially diverse sample of young adults. J Adolesc Health 2008;42:237–42. https://doi.org/10.1016/j.jadohealth.2007.08.022. [5] Jones M, Cook R. Intent to receive an HPV vaccine among university men and women and implications for vaccine administration. J Am Coll Health 2008;57:23–32. https://doi.org/10.3200/JACH.57.1.23-32. [6] Krawczyk AL, Perez S, Lau E, Holcroft CA, Amsel R, Knäuper B, et al. Human papillomavirus vaccination intentions and uptake in college women. Health Psychol 2012;31:685–93. https://doi.org/10.1037/a0027012. [7] Rosenthal SL, Weiss TW, Zimet GD, Ma L, Good MB, Vichnin MD. Predictors of HPV vaccine uptake among women aged 19–26: importance of a physician’s recommendation. Vaccine 2011;29:890–5. https://doi.org/10.1016/ j.vaccine.2009.12.063. [8] Craciun C, Ba˘ban A. ‘‘Who will take the blame?”: Understanding the reasons why Romanian mothers decline HPV vaccination for their daughters. Vaccine 2012;30:6789–93. https://doi.org/10.1016/j.vaccine.2012.09.016. [9] World Health Organization [WHO] (2016). European Health for All Database. Retrieved from http://data.euro.who.int/hfadb/. [10] Voida˘zan S, Morariu SH, Tarcea M, Moldovan H, Dobreanu M. Human papilloma virus (HPV) infection and HPV vaccination: assessing the level of knowledge among students of the university of medicine and pharmacy of Tirgu Mures Romania. Acta Dermatovenerol. Croatica 2016;24:193. [11] Larson HJ, Jarrett C, Eckersberger E, Smith DM, Paterson P. Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: a systematic review of published literature, 2007–2012. Vaccine 2014;32:2150–9. https://doi.org/10.1016/j.vaccine.2014.01.081. [12] Betsch C, Böhm R, Airhihenbuwa CO, Butler R, Chapman GB, Haase N, et al. Improving medical decision making and health promotion through culturesensitive health communication: An agenda for science and practice. Med Decis Making 2016;36:811–33. https://doi.org/10.1177/0272989X15600434. [13] MacDonald, N.E. & SAGE Working Group on Vaccine Hesitancy. (2015). Vaccine hesitancy: Definition, scope and determinants. Vaccine, 33, 4161-4164. doi: 10.1016/j.vaccine.2015.04.036. [14] Satterwhite CL, Torrone E, Meites E, Dunne EF, Mahajan R, Ocfemia MCB, et al. Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2008. Sex Transm Dis 2013;40:187–93. https://doi.org/ 10.1097/OLQ.0b013e318286bb53.
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Please cite this article as: M. A. Pentßa, I. C. Cra˘ciun and A. Ba˘ban, The power of anticipated regret: Predictors of HPV vaccination and seasonal influenza vaccination acceptability among young Romanians, Vaccine, https://doi.org/10.1016/j.vaccine.2019.11.042