As a whole, 40.2% (212/527) of the NH staff members fulfilled the questionnaire, and 51.8% of them (110/212) declared to be in favor of getting the influenza vaccination in the 2019–2020 season. Among those, 83.6% (92/110) expressed one or more reasons for this choice, while among the unfavorable, only 60.7% (62/102) stated the reasons.
3.1.1. Reasons to Get Vaccinated
Three macro-categories emerged from the qualitative analysis of the answers that motivated the intention to get the vaccine; within each of them, sub-categories were then identified (Table 1
The first identified macro-category refers to risk perception. It assumes an appropriate knowledge of the disease and the risks associated with it, the awareness of performing a profession in a context that exposes more to the likelihood of contracting the virus, and the desire to protect himself/herself and the others.
Among those workers who declared their intention in favor of getting the vaccine, 83.7% (77/92) have referred reasons in this macro-category, which therefore represents the core category of those who declared themselves in favor of vaccination. From the analysis of the motivations that fall within the perception of risk, two sub-categories were then identified: protection and awareness of working in a place at higher risk.
(A.1) Protection is an explicit intention aimed at protecting oneself and people nearby (family, colleagues, nursing homes residents, other people). In particular, most workers explicitly refer to the desire to protect both the private (themselves or their family) and the public dimension (colleagues and nursing home residents):
“To avoid flu and to protect my family and NH residents, because they are fragile people” (respondent NH_5_3)
“In my opinion, vaccination is the (...) safest means of not transmitting it (influenza) to the NH residents and also to family members” (respondent NH_1-2_15)
A smaller group is concerned only with personal protection and close affections:
“I have already had the vaccine to prevent getting sick” (respondent NH_1-2_11)
“Protect me and my family” (respondent NH_1-2_21)
Few refer to the protection of the public sphere alone:
“To avoid infecting NH residents” (respondent NH_5_6)
“I would like to get vaccinated to protect the health of fragile subjects with whom I am in daily contact” (respondent NH_8_25)
Although the main message in this subcategory is protection (towards himself/herself or others) through the vaccine, this motivation also contains an attitude of “trust in the vaccine”. This connection emerges mainly referring to personal protection or close relationships:
“To raise my immunity” (respondent NH_8_64)
“Too many times I find myself with low immune defenses and therefore avoid or reduce the chances of catching other viruses, also protecting my family” (respondent NH 8_42)
At the same time, the protection for colleagues and NHs residents, together with trust in the vaccine, calls for awareness of social responsibility, which is the will to protect others by vaccinating themselves:
“Because I want to protect (...) especially all those who cannot be vaccinated” (respondent NH_1-2_34)
“Protection towards others and helping people without immune defenses who cannot be vaccinated to feel safe in the midst of many other people who have the possibility and the luck of being able to get vaccinated” (respondent NH_8_10)
(A.2) Awareness of working in a place at higher risk. In this second sub-category, the awareness of being in a context that exposes more to the likelihood of contracting and transmitting influenza are mainly emphasized. Hence, the intention to adopt protective behaviors:
“Since we do work at risk” (respondent NH_1-2_13)
“I work in a social health facility and there is a greater risk of getting the influenza” (respondent NH_8_18)
The second identified macro-category concerns the dimension of values, that is the set of ideals or norms of the individuals of a social group, which influence their action. Within this macro-category, two sub-categories have been identified.
(B.1) Prevention. The first sub-category refers to a generic motivation for prevention, meant as the will to prevent the negative effects of the influenza for individual and social benefit. This behavioral norm implies the appropriateness of a behavior aimed at preventing the disease. In this sense, although it is also closely linked to the perception of risk, prevention has been included in the dimension of values:
“I think prevention is important” (respondent NH_8_73)
(B.2) Social responsibility. The second sub-category refers to social responsibility, where the collective benefit stands out as a value that guides one’s intention to get vaccinated:
“It is a favor that should not be wasted and a social duty” (respondent NH_5_3)
“Civic sense” (respondent NH_8_31)
The third macro-category concerns trust, an attitude resulting from a positive assessment of facts, circumstances, relationships, for which one trusts-in this case-in the vaccine and more generally in the healthcare system and in the professionals, animated by a general feeling of safety. Trust can therefore be characterized into two sub-categories, as follow.
(C.1) Trust from experience/habits. It refers to the sense of safety and efficacy of the vaccine, mainly referred to the protection of one’s health. The basis of this choice is therefore the assumption that the vaccine works well because it is based on a positive experience, which corresponds to expectations:
“In my opinion, vaccination is the most effective means of preventing influenza (...)” (respondent NH_1-2_15)
“I am in favor of vaccines. I don’t want to get sick” (respondent NH_6_3)
This category also includes the motivations of staff members who refer to adopt the choice of getting vaccinated as a habit, recalling the systematic and repetitive nature of the action. Also, in this case, a reference to the expectations of the vaccine effectiveness is implicit, so much so that this choice becomes a personal habit:
“Already done. Always done and I’m fine” (respondent NH_3_15)
“For many years I have been vaccinated to protect the health of assisted guests and my family members because until a few years ago I had a family member at risk” (respondent NH_6_4)
As we can see from these motivations, trust in the vaccine recalls the macro-category of reference values (prevention and social responsibility) and awareness of the risk associated with contracting and transmitting influenza.
(C.2) Trust from the General Practitioner (GP). The trust coming from the GP or from other healthcare professionals includes the motivations of all staff members declaring to get the vaccine because they were advised by their referring doctor:
“As an asthmatic, the family doctor strongly advised me to get the vaccine” (respondent NH_8_50)
“On the advice of doctors” (respondent NH_6_7)
3.1.2. Reasons to Not Get Vaccinated
Four macro-categories emerged from qualitative analysis of motivations for not being vaccinated; within each of them, sub-categories were then identified (Table 2
As for motivations of those who declare their intention in favor of vaccine, the macro-category of risk perception is the most represented (55%) among those against the vaccine too. Their negative attitude is represented by poor or distorted knowledge of personal or social risk of influenza, assuming that it is not a serious disease. This option is strengthened by a lack of interest in exploring the topic.
From the analysis of answers related to risk perception, two sub-categories were then identified, “uselessness of vaccine” and “complacency”.
(A.1) Uselessness of vaccine. It is the most represented sub-category (42%) among those who are opposed to vaccination. It refers to the perception of unnecessariness about the opportunity of being vaccinated, with regard to one’s health.
Specifically, in the majority of cases, staff members motivated their perception of uselessness of vaccine with their “invulnerability” to seasonal flu, claiming that they never get sick:
“It’s hard for me to get the influenza” (respondent NH_7_5)
“I am not a person who gets sick easily, my immune defenses are very strong” (respondent NH_1-2_18)
It is worth noticing that this motivation contains a prominent attitude to “individualism”, a value referring to take care of oneself but not for others. It is absent the principle of reciprocity, which pushes an individual to get vaccinated to protect others, as others protect him/her.
Other respondents report a perception of “general uselessness”, without detailing why they believe that:
“I believe it’s not necessary” (respondent NH_9_3)
“I think that getting vaccinated is not useful for me” (respondent NH_8_44)
At last, in a few cases, uselessness is motivated by not being in contact with older people in the workplace.
Compared to previous opinions, which mainly refer to generic or personal absence of risk perception, this motivation also reveals a lack of knowledge of flu ways of transmission:
“I don’t work closely with residents and I don’t get sick frequently with influenza” (respondent NH_4_8)
“I am not in direct contact with patients” (respondent NH_8_6)
(A.2) Complacency attitude. The perception of risk includes a second sub-category, the complacency attitude, that is affected by the habit. Here, the opposition to vaccination lies on maintaining the habit of never getting vaccinated.
In this case, the attitude seems to be oriented towards passivity, not questioning one’s choice, as well as towards a lack of values (already described) towards others’ protection and social responsibility. The habit of not getting vaccinated tends to affect the individual behavior much more than any negative experiences or distrust with vaccines. It is described as the prevailing power of inertia, and the maintenance of the status quo: changing one’s mind is in fact one of the most difficult challenges to fulfill for those who work on the architecture of choices in vaccine.
It is interesting to notice that habit has a double effect, on those who are in favor as well as on those against vaccination, but with opposite consequences: trust in personal and social benefit vs. disinterest for others and scarce risk perception for oneself:
“I don’t get vaccinated because I never did it” (respondent NH_6_10)
“I haven’t been vaccinated until now, so I prefer not to do it this year either” (respondent NH_6_8)
The second macro-category refers to “distrust”, defined as an attitude of negative evaluation of facts, circumstances, and relationships, generating a feeling of distrust in others as well as in their own possibilities and generally producing a lack in self-confidence and peace of mind.
About the attitude concerning vaccination, in distrust, we can identify two sub-categories: distrust in safety and distrust in effectiveness.
“Distrust in effectiveness” is based on the belief that vaccination is an avoidable practice because it does not bring any benefits, even if it is not harmful, recalling the category of “uselessness of vaccine”.
(B.1) Distrust in safety. The majority of staff members who report reasons related to distrust refer to “distrust in safety” of vaccines, which seems to derive from negative experiences with vaccine:
“I had physical weakness in previous times” (respondent NH_8_22)
“Because once I got vaccinated and I felt worse than when I didn’t” (respondent NH_5_19)
(B.2) Distrust in effectiveness. The second sub-category, reported by a smaller number of workers, refers to “distrust in effectiveness” of vaccination practice:
“Once I got vaccinated but I got the flu anyway” (respondent NH_1-2_2)
“I don’t think it’s effective” (respondent NH_1-2_3)
As for motivations of those who declare their intention in favor of vaccine, the macro-category of “values dimension” has been identified for those against as well. It includes a gap in ideals or norms based on healthcare workers’ awareness of their responsibilities, specifically on the norm of social protection (fragile and non-frail subjects), also achievable through personal protection. This can lead to opposition and criticism of the vaccine or to a partial perception of its individual and social usefulness.
Two sub-categories have been identified.
(C.1) Upset. Answers are characterized by short and poorly argued positions. In this case, respondents’ values seem to guide them towards a very extreme position of refusal to get vaccinated.
The transmitted message refers to the denial of flu vaccination importance:
“Anti-vax” (respondent NH_9_1)
“I am against it” (respondent NH_8_60)
(C.2) Lacking professional responsibility. The second sub-category refers to scarce or limited awareness of the responsibility of getting the vaccine owing to one’s profession. In general, this attitude calls for a lack of knowledge about the individual and social risk of contracting the flu virus. This does not necessarily involve totally disregarding vaccination importance, but it is not associated with a professional duty and it can lead to more extreme positions, i.e., the intention to “exploit” the others’ immunity for personal protection:
“I take advantage of herd immunity of nursing home’s residents” (respondent NH_1-2_39)
“I personally believe that influenza vaccine is very useful for elderly and immunocompromised but not necessary for others, even those in contact with these diseases” (respondent NH_8_55)
The last macro-category identified refers to “reasons related to one’s health”.
Respondents justify their attitude towards vaccination as derived from aspects related to physical inability to do vaccines. Some workers, for example, declare that they cannot be vaccinated due to an autoimmune disease for which, indeed, this practice is not indicated:
“I have an active autoimmune disease treated with immunosuppressive therapy” (respondent NH_8_1)
“Autoimmune subject. I do homeopathic vaccine” (respondent NH_7_13)
However, in other cases, respondents’ health fears are not accredited by scientific evidence. This distrust or distorted knowledge tends to determine a negative attitude towards vaccination:
“I have only one kidney and I don’t want to overload my organism” (respondent NH_6_1)
“This year I have already got other vaccinations and I don’t feel like getting too many vaccines in the same period (I probably can’t even get them close together)” (respondent NH_8_55)