Article

Intention, Motivation, and Empowerment: Factors Associated

with Seasonal Influenza Vaccination among Healthcare
Workers (HCWs)
Thalia Bellali 1,2, *, Polyxeni Liamopoulou 2 , Savvato Karavasileiadou 3 , Noura Almadani 3 , Petros Galanis 4 ,
George Kritsotakis 5 and Georgios Manomenidis 6

1 Department of Health Sciences, School of Sciences, European University Cyprus, Nicosia 2404, Cyprus
2 Faculty of Nursing, International Hellenic University, 57400 Thessaloniki, Greece; [email protected]
3 Department of Community Health Nursing, College of Nursing, Princess Nourah bint Abdulrahman
University, Riyadh 11671, Saudi Arabia; [email protected] (S.K.); [email protected] (N.A.)
4 Faculty of Nursing, National and Kapodistrian University of Athens, 11524 Athens, Greece;
[email protected]
5 Department of Business Administration & Tourism, Hellenic Mediterranean University,
72300 Herakleion, Greece; [email protected]
6 Faculty of Nursing, International Hellenic University, Didimoteicho Branch, 57400 Thessaloniki, Greece;
[email protected]
* Correspondence: [email protected] or [email protected]; Tel.: +30-6947833186

Abstract: Background: Vaccination against seasonal influenza has proven effective in preventing noso-
comial influenza outbreaks among hospital patients and healthcare workers (HCWs). This study aims
to explore the intention, motivation, and empowerment toward vaccination and vaccination advocacy
as contributing factors for seasonal influenza vaccination in HCWs. Methods: A cross-sectional study
in eight secondary hospitals in Greece was conducted from March to May 2022. An anonymous
questionnaire was enclosed in an envelope and distributed to all participants, including questions on
Citation: Bellali, T.; Liamopoulou, P.; vaccine behavior and the MoVac-flu and MoVad scales. Results: A total of 296 participants completed
Karavasileiadou, S.; Almadani, N.; the questionnaire. In multivariate logistic regression models adjusted for potential confounders,
Galanis, P.; Kritsotakis, G.; increased age, intention score, MoVac-flu scale score, and the presence of chronic diseases were
Manomenidis, G. Intention,
significant predictors of influenza vaccination this year, while increased age, intention score, and
Motivation, and Empowerment:
presence of chronic diseases were predictors of vaccination every year. Conclusion: Vaccination
Factors Associated with Seasonal
uptake is simultaneously affected by logical cognitive processes (intention), together with factors
Influenza Vaccination among
related to motivation and empowerment in distinct self-regulatory domains such as value, impact,
Healthcare Workers (HCWs).
Vaccines 2023, 11, 1508. https://
knowledge, and autonomy. Interventions focused on these identified predictors may be used as a
doi.org/10.3390/vaccines11091508 guide to increase HCWs’ vaccination rates.

Academic Editor: Pedro

Keywords: behavior; healthcare workers; influenza; vaccination; factors
Plans-Rubió

Received: 5 August 2023

Revised: 16 September 2023
Accepted: 20 September 2023 1. Introduction
Published: 21 September 2023 Healthcare workers (HCWs) are at a high risk of becoming infected with seasonal
influenza infection and subsequently infecting their patients due to direct patient care and
the asymptomatic character of the influenza virus. Potentially severe complications of in-
fluenza infection may lead to increased morbidity and mortality in patients with additional
Copyright: © 2023 by the authors.
underlying medical conditions [1]. According to the World Health Organization (WHO),
Licensee MDPI, Basel, Switzerland.
up to 500,000 people die because of influenza complications [2], while the annual economic
This article is an open access article
distributed under the terms and
burden is estimated to be around USD 11.2 billion in the USA [3] and EUR 77 million on
conditions of the Creative Commons
hospitalizations in Europe [4]. Economic hardships caused by work absences and low
Attribution (CC BY) license (https:// productivity are an additional health system burden [5]. Vaccination is considered the most
creativecommons.org/licenses/by/ effective tool for managing the spread of this infection [6,7].
4.0/).

Vaccines 2023, 11, 1508. https://doi.org/10.3390/vaccines11091508 https://www.mdpi.com/journal/vaccines

Vaccines 2023, 11, 1508 2 of 12

Despite the WHO’s recommendations for annual vaccination [2], the rates of vaccine
uptake among European HCWs, according to the European Center for Disease Prevention
and Control (ECDC), vary distinctively [8] and are largely poor, with a coverage rate of
25.7% (5.0% to 54.4%) for the 2014-15 season [9], if one considers the aim of 75% uptake for
people aged 65 recommended by the WHO [2]. In France, nurses had the least favorable
opinions about seasonal influenza vaccination (SIV) compared to other vaccines. Only
one-third were vaccinated in one season [10,11]. In Greece, SIV uptake is estimated at
approximately 24.7% [12], although higher percentages (57%) have been reported for
general practitioners [13]. In line with these results, Kopsidas et al. [14] said that only
24% of nurses and 60% of doctors were vaccinated in a tertiary pediatric hospital.
The introduction of a previously unknown new virus named SARS-CoV-2 at the
beginning of 2020 played a significant part in reducing the circulation of the influenza virus,
disrupting the spread of the disease mainly because of the use of face masks. The focus
of public attention on COVID-19 led to a lower demand for the influenza vaccine and a
decline in flu vaccination due to the convergence of influenza and COVID-19 vaccinations,
as according to guidelines, a space of at least 2 weeks is suggested. However, in certain age
groups (i.e., elderly), vaccination uptake remained stable [15].
Many factors have been shown to determine influenza vaccination uptake. In an Italian
study of HCWs in various healthcare facilities, chronic illnesses, and smoking habits were
pivotal factors for SIV [16]. Several studies have also associated the following demographic
variables with HCWs’ intention to receive the seasonal influenza vaccination: age, gender,
and profession. Male and older HWCs were more likely to receive the SIV [10,13,17], and
nurses displayed lower intention to receive the SIV when compared to physicians [18].
As mentioned above, the main shortcoming of those studies is that they need to rely
on a theory to interpret their findings. Among the early but still relevant theories trying to
explain the underlying reasons for human behavior in a particular context and a specific
time (in this case, vaccination uptake) are the ‘Theory of Reasoned Action’(TRA) and the
‘Theory of Planned Behavior’ (TPB) [19,20].
The ‘TPB’, proposed by Ajzen [20,21], is based mainly on Ajzen and Fishbein’s
‘TRA’ [22], where an individual who intends to perform a behavior has more chances
to act accordingly. People do not make health-related decisions in a vacuum but rather
in a particular physical, socio-cultural, and political context with specific barriers and
facilitators [23–26]. To overcome this barrier, a perceived behavior control was added as a
significant variable to the ‘TRA’, forming the ‘TPB’ [21].
Based on the above theories, extensive efforts have been made to define the determi-
nants of HCWs’ intention to receive the seasonal influenza vaccination. A study conducted
in Singapore on HCWs working in an acute care tertiary hospital investigated the associa-
tion between psychosocial beliefs and vaccine uptake using the Health Belief Model-‘HBM’,
an earlier theory of the ‘TRA’ [25,27]. It concluded that the higher HCWs’ perceptions of vac-
cine effectiveness, the higher the intention for vaccine uptake [28]. In Europe, Boey et al. [29]
surveyed HCWs from various hospitals and nursing homes in Belgium using the Health
Belief and additional models [22,30]. They found that HCWs’ efforts to protect their fami-
lies and environments were essential factors that affected vaccination behavior. All these
studies were based on theories that tried to explain HCWs’ beliefs on influenza vaccine
uptake based on their rational consideration of the cost and benefits of this action [31].
People do not always make rational and coherent choices but rather choices based
on the norms of the broader social environment and their emotions [23,24,32]. As such,
they may engage (or not) in a behavior because other people do it because of how they
feel or as a coping mechanism, not because it is the right thing to do or the wrong thing to
avoid [33]. The Cognitive Model of Empowerment (CME) offers a basis for investigating
vaccine and health-related behaviors [34–36]. The ‘CME’ states that individuals engage
in conduct not only based on their rational thoughts but also based on their feelings in
four distinct domains: value; impact; autonomy and knowledge [36].
Vaccines 2023, 11, 1508 3 of 12

A recent study tried to advance our understanding of the determinants of HCWs’

intention to receive the SIV using the ‘CME’ [35]. The authors examined the feelings
that determine why HCWs may want to get vaccinated in six European countries, in
addition to explaining influenza vaccination uptake as a weighted process of a cost–benefit
action [34–36]. They concluded that self-perceived efficacy was the primary factor for
vaccination advocacy from the HCWs.
The present study aimed to simultaneously test the predictive value of the ‘TPB’ and
the ‘CME’ to explore intention, motivation, and empowerment towards influenza vaccina-
tion and vaccination advocacy as contributing factors to seasonal influenza vaccination. In
this way, we can examine the possible intercorrelation of rational reasoning and emotional
factors in vaccine uptake.

2. Materials and Methods

2.1. Study Design and Population
A cross-sectional study was conducted between March and May 2022. The target
population was a convenience sample of HCWs in 8 secondary hospitals in a northern
province of Greece (response rate 74%). Inclusion criteria were having at least one year of
experience and permanent employment status. Posters describing the study were placed
outside the nursing stations of all hospital departments. An anonymous questionnaire
explaining the study’s purpose and contact information was enclosed in an envelope and
distributed to all participants. They were then asked to return it sealed in a general mailbox
placed in every department. The time for completion was approximately 15–20 min.

2.2. Measures
Participants reported their influenza vaccination status this year and if they received the
seasonal influenza vaccine every year. They also provided information on the below topics.

2.2.1. Demographics
Demographic data included participants’ gender, age, marital status, number of
children, profession (physicians, nurses, nurse assistants), working department, level of
education, and years of working experience.

2.2.2. Intention for Vaccination Uptake Based on the Theory of Planned Behavior
A questionnaire constructed based on the ‘TPB’ guidelines assessed the intention for
vaccination uptake. It was previously used in a Greek elderly population [37] and was
then adapted for HCWs. The questionnaire consists of four subscales that correspond to
attitudes (3 items), subjective norms (6 items), perceived behavioral control (4 items), and
intention (2 items). The attitudes subscale defines attitudes towards vaccination uptake. The
subjective norms subscale includes statements concerning the expectation of HCWs’ social
context to uptake vaccination. The perceived control subscale reflects individual control in
receiving the vaccine. Finally, the intention scale assesses the desire for vaccination. All
items were measured on a 7-point Likert scale ranging from 1, “strongly disagree,” to 7,
“strongly agree”. A higher score indicates positive attitudes and beliefs regarding influenza
vaccination, higher social pressure, higher possibility of getting a vaccine shot, etc. To
ensure the quality of the adapted version for HCWs, the questionnaire was distributed
through a pilot study to a group of twenty nurses/nurse assistants and ten physicians who
were asked about inconsistencies. The face validity of the questionnaire was excellent since
there were no comments/questions/misunderstandings. The Cronbach’s alpha coefficients
for the four subscales ranged from a = 0.73 (perceived control scale) to a = 0.95 (intention
scale), indicating acceptable to excellent reliability.

2.2.3. Cognitive Empowerment towards Influenza Vaccination and Vaccination Advocacy

Cognitive empowerment towards influenza vaccination and vaccination advocacy
were assessed by the ‘Motors of influenza vaccination acceptance’ (MoVac-flu) and the
Vaccines 2023, 11, 1508 4 of 12

‘Motors of engagement with vaccination advocacy’ (MovAd) scales, respectively [36]. These
two scales consist of 9 and 11 items and are measured on a 7-point Likert scale ranging from
1, “strongly disagree,” to 7, “strongly agree”. They assess the empowerment feelings of
HCWs about the value (the flu jab plays a vital role in protecting my life and that of others),
impact (vaccination greatly reduces my risk of catching the flu), knowledge (I understand
how the flu jab helps my body fight the flu virus), and autonomy (I can choose whether
to get a flu jab or not) about vaccinations (MoVac-flu) and the advocacy of vaccinations
(MovAd). All the above indicative items in this paragraph come from the MoVac-flu
scale. The Greek versions of the MoVac-flu and the MovAd scales have good psychometric
properties [37,38]. Cronbach’s α internal consistency coefficients were α = 0.94 and α = 0.92,
respectively, indicating excellent internal reliability.

2.2.4. Other Predictors of Vaccination Behavior

Participants reported on smoking habits and the presence of chronic illnesses.

2.3. Statistical Analysis

Continuous variables are presented as means (standard deviation), while categorical
variables are presented as percentages. The Kolmogorov–Smirnov test indicated the distri-
bution of the continuous variables and the need for parametric methods. Bivariate analysis
was performed between independent variables and vaccination status (chi-square test,
chi-square trend test, and independent samples t-test). Subsequently, we used multivariate
logistic regression models (odds ratios with 95% confidence intervals) to adjust for potential
confounders. Independent variables significantly associated (p < 0.20) in bivariate analysis
were entered into the backward stepwise multivariate logistic regression analysis with vac-
cination status as the dependent variable. Criteria for entry and removal of variables were
based on the likelihood ratio test (enter/remove limits of p < 0.05 and p > 0.10, respectively).
All two-sided statistical tests and p-values < 0.05 were considered statistically significant.
Statistical analyses were performed using SPSS v.21.0 (IBM SPSS Statistics for Windows,
Armonk, NY, USA: IBM Corp.).

2.4. Compliance with Ethical Standards

Ethical approval was obtained from all hospitals’ Ethical Review Boards. Participation
in the study was voluntary and was performed according to the ethical standards of the
Declaration of Helsinki as revised in Brazil. Informed consent was considered positive
when participants returned the completed questionnaires.

3. Results
Of the 400 HCWs who received the survey, 296 responded. The mean age of HCWs
was 43.3 years, and most participants were female (84.8%). Regarding vaccination status,
24.3% (n = 72) of the HCWs stated that they received the influenza vaccine this year, while
20.9% (n = 62) said they accept it yearly. Demographics and other characteristics are
illustrated in Table 1.

Table 1. Demographic, professional, and behavioral characteristics of HCWs.

Characteristics n %
Gender
Males 45 15.2
Females 251 84.8
Age 43.3 a 8.7 b
Marital status
Singles/divorced/widows 83 28.0
Vaccines 2023, 11, 1508 5 of 12

Table 1. Cont.

Characteristics n %
Married 213 72.0
Children
No 76 25.7
Yes 220 74.3
Occupation
Physicians 37 12.5
Nurses 177 59.8
Nurse assistants 82 27.7
Department
General internal medicine 201 71.5
ICUs 80 28.5
Educational level
Secondary education 84 28.4
Tertiary education 179 60.5
MSc/PhD 33 11.1
a
Years of experience 16.2 9.7 b
Smoking
No 196 66.2
Yes 100 33.8
Chronic disease
No 269 90.9
Yes 27 9.1
a Mean, b standard deviation.

Mean scores for subscales of the ‘Intention for vaccination uptake’ were above the
mid-point (=3), indicating positive beliefs and an intention towards vaccination. In the
same way, mean scores on the MoVac-flu scale, the MovAd scale, and the subscales were
above the mid-point (=4), indicating high internal motivation and advocacy towards
vaccination—Table 2.

Table 2. Descriptive statistics for scales of TPB model, MoVac-flu scale, and MovAd scale.

Standard Minimum Maximum Cronbach’s

Scale Mean Median
Deviation Value Value Alpha
Behavioral beliefs 3.4 1.0 3.3 1 5 0.94
Normative beliefs 3.1 0.8 3.2 1 5 0.87
Control beliefs 3.8 0.5 3.8 2 5 0.63
Intention 3.0 1.1 3 1 5 0.95
MoVac-flu scale 4.7 1.3 4.6 1 7 0.92
Value 4.4 1.7 4.3 1 7
Impact 4.3 1.7 4.3 1 7
Knowledge 5.3 1.3 5.3 1 7
Autonomy 6.1 1.4 7 1 7
Vaccines 2023, 11, 1508 6 of 12

Table 2. Cont.

Standard Minimum Maximum Cronbach’s

Scale Mean Median
Deviation Value Value Alpha
MovAd scale 4.8 1.2 4.9 1 7 0.92
Value 4.7 1.6 5 1 7
Impact 4.6 1.5 4.7 1 7
Knowledge 4.8 1.6 5 1 7
Autonomy 5.4 1.4 6 1 7

Bivariate analysis between independent variables and vaccination status is shown

in Table 3, while multivariate logistic regression analysis is shown in Table 4. According
to the bivariate analysis, the percentage of vaccinated males was about twice as high as
the percentage of females, while physicians were more frequently vaccinated than nurses
and nurse assistants. Also, a higher age and educational level were related to a greater
probability of vaccination. All scales of the Planned Behavior model (behavioral beliefs,
normative beliefs, control beliefs, and intention score) were positively related to vaccination
status. Vaccinated HCWs had higher scores on the MoVac-flu scale and the MovAd scale.

Table 3. Bivariate analysis between independent variables and vaccination status.

Vaccination This Year Vaccination Every Year

p-Value p-Value
No Yes No Yes
n % n % n % n %
Gender 0.002 a 0.009 a
Males 26 57.8 19 42.2 29 64.4 16 35.6
Females 198 78.9 53 21.1 205 81.7 46 18.3
Age 42.9 b 8.7 c 45.4 b 8.4 c 0.03 d 42.8 b 8.3 c 45.4 b 9.6 c 0.04 d
Marital status 0.9 a 0.6 a
Singles/divorced
63 75.9 20 24.1 64 77.1 19 22.9
/widows
Married 161 75.6 52 24.4 170 79.8 43 20.2
Children 0.7 a 0.9 a
No 59 77.6 17 22.4 60 78.9 16 21.1
Yes 165 75.0 55 25.0 174 79.1 46 20.9
Occupation 0.004 a 0.007 a
Physicians 20 54.1 17 45.9 22 59.5 15 40.5
Nurses 138 78.0 39 22.0 145 81.9 32 18.1
Nurse assistants 66 80.5 16 19.5 67 81.7 15 18.3
Department 0.6 a 0.8 a
ICUs 62 77.5 18 22.5 64 80.0 16 20.0
General Internal
150 74.6 51 25.4 158 78.6 43 21.4
medicine
Educational level 0.02 e 0.006 e
Secondary education 68 81.0 16 19.0 69 82.1 15 17.9
Tertiary education 137 76.5 42 23.5 148 82.7 31 17.3
MSc/PhD 19 57.6 14 42.4 17 51.5 16 48.5
Vaccines 2023, 11, 1508 7 of 12

Table 3. Cont.

Vaccination This Year Vaccination Every Year

p-Value p-Value
No Yes No Yes
n % n % n % n %
b c b c d b c b 9.4 c
Years of experience 16.5 9.9 17.5 9.4 0.4 16.5 9.9 17.7 0.4 d
Smoking 0.7 a 0.9 a
No 147 75.0 49 25.0 155 79.1 41 20.9
Yes 77 77.0 23 23.0 79 79.0 21 21.0
Chronic disease 0.01 a 0.002 a
No 209 77.7 60 22.3 219 81.4 50 18.6
Yes 15 55.6 12 44.4 15 55.6 12 44.4
b c b c d b c b 0.7 c
Behavioral beliefs 3.2 0.9 4.2 0.9 <0.001 3.2 0.9 4.4 <0.001 d
Normative beliefs 3.0 b 0.7 c 3.6 b 0.7 c <0.001 d 3.0 b 0.7 c 3.7 b 0.6 c <0.001 d
Control beliefs 3.8 b 0.5 c 4.0 b 0.5 c 0.04 d 3.8 b 0.5 c 3.9 b 0.5 c 0.3 d
Intention score 2.6 b 0.9 c 4.1 b 0.9 c <0.001 d 2.7 b 0.9 c 4.2 b 0.7 c <0.001 d
MoVac-flu scale 4.3 b 1.2 c 5.9 b 1.1 c <0.001 d 4.4 b 1.2 c 6.0 b 0.8 c <0.001 d
MovAd scale 4.7 b 1.2 c 5.3 b 1.1 c <0.001 d 4.6 b 1.2 c 5.7 b 0.9 c <0.001 d
a Chi-square test, b mean, c standard deviation, d independent samples t-test, and e chi-square trend test.

Table 4. Multivariate logistic regression analysis with vaccination status as the dependent variable
(no vaccination: reference category).

Dependent Variable 95% Confidence Interval

Odds Ratio p-Value
Independent variable for Odds Ratio
Vaccination this year
Males vs. females 1.70 0.62 to 4.62 0.300
Age 1.05 1.01 to 1.10 0.016
Married vs. singles/divorced/widows 2.01 0.58 to 7.06 0.274
No children vs. children 1.29 0.33 to 5.02 0.712
Physicians vs. nursing staff 1.47 0.46 to 4.74 0.517
Educational level
Tertiary education vs.
1.10 0.43 to 2.81 0.846
secondary education
MSc/PhD vs. secondary education 1.36 0.34 to 5.49 0.664
Years of experience 1.04 0.97 to 1.10 0.280
Smokers vs. non smokers 1.25 0.54 to 2.88 0.605
Chronic disease vs. no 3.78 1.20 to 11.93 0.024
Behavioral beliefs 1.56 0.79 to 3.09 0.198
Normative beliefs 0.60 0.27 to 1.33 0.207
Control beliefs 1.70 0.73 to 3.98 0.220
Intention score 4.05 2.39 to 6.89 <0.001
Life Orientation Test 0.95 0.84 to 1.08 0.948
MoVac-flu scale 1.56 1.03 to 2.37 0.038
MovAd scale 0.86 0.54 to 1.38 0.532
Vaccines 2023, 11, 1508 8 of 12

Table 4. Cont.

Dependent Variable 95% Confidence Interval

Odds Ratio p-Value
Independent variable for Odds Ratio
Vaccination every year
Males vs. females 1.68 0.53 to 5.29 0.377
Age 1.05 1.00 to 1.09 0.041
Married vs. singles/divorced/widows 1.21 0.29 to 5.00 0.796
No children vs. children 1.23 0.26 to 5.77 0.791
Physicians vs. nursing staff 0.59 0.15 to 2.35 0.461
Educational level
Tertiary education vs.
0.73 0.26 to 2.09 0.559
secondary education
MSc/PhD vs. secondary education 1.97 0.42 to 9.20 0.390
Years of experience 1.02 0.95 to 1.10 0.578
Smokers vs. non smokers 1.67 0.64 to 4.36 0.300
Chronic disease vs. no 6.79 2.04 to 22.61 0.002
Behavioral beliefs 2.07 0.93 to 4.58 0.074
Normative beliefs 0.78 0.33 to 1.87 0.578
Control beliefs 0.49 0.19 to 1.33 0.162
Intention score 7.27 4.36 to 12.13 <0.001
Life Orientation Test 1.11 0.96 to 1.29 0.151
MoVac-flu scale 1.56 0.84 to 2.89 0.160
MovAd scale 1.10 0.62 to 1.96 0.745

A multivariate analysis identified that increased intention score and age were asso-
ciated with a greater probability of vaccination during this year (p < 0.001 and p = 0.016,
respectively) and every year (p < 0.001 and p = 0.041, respectively). Also, an increased score
on the MoVac-flu scale was associated with an increased probability of vaccination during
this year (p < 0.001). HCWs with a chronic disease had a greater probability of vaccination
during this year (p = 0.024) and every year (p = 0.002).

4. Discussion
The present study simultaneously tested the associations of two theories based on
rational reasoning and motivation and empowerment with seasonal influenza vaccination
in Greek HCWs. It showed that significant predictors of influenza vaccination uptake this
year included an older age, the presence of chronic diseases, an increased score in intention
(as conceptualized in the ‘TPB’), and an increased score in the motivation for vaccination
(MoVac-flu scale, as conceptualized in the ‘CME’). In contrast, yearly influenza vaccination
was associated with advanced age, chronic diseases, and intention scores. Thus, this an
essential addition to the current literature for both theories. However, they have different
starting points that focus on rational reason and emotions and provide valuable insights on
influenza vaccination uptake in HCWs.
In the current study, only the MoVac-flu scale exhibited significant associations with
vaccination in multivariable logistic models, which highlights the importance of considering
cognitive empowerment as an important factor when implementing programs that aim
to promote vaccination uptake in HCWs. In addition, this finding partially agrees with a
recent study in six European countries in which increased engagement in influenza vaccine
uptake was associated with higher scores on all MoVac-flu and MovAd subscales [35].
Still, there were some differences between the associations in the participating countries,
Vaccines 2023, 11, 1508 9 of 12

implying the possible existence of other country-specific norms [39] that are related to
vaccine uptake.
In the study of Dardalas et al. [37] in Greece of individuals over 60, no associations
were reported between MoVac-flu and MovAd scales and influenza vaccination, and the
intention score was its strongest predictor. It may be the case that healthcare professionals
have different reasons for vaccination than the general population, but this notion should
be further tested via empirical research. What is of interest in the study above is that
the general population reported similar or higher scores in many MoVac-flu and MovAd
subscales as the sample of HCWs in this study. More specifically, in this sample, the mean
MoVac-flu scale total score, mean Value, and mean impact subscale scores were 4.7, 4.4, and
4.3, respectively, compared to 5.4, 5.5, and 4.8 in the sample of people over 60. There were
no other prominent differences between the samples, except for the MovAd knowledge
subscale, which was higher in HCWs. Older people who face more chronic diseases and
have more frequent contact with the health care system are well-informed and empowered
concerning SIV because influenza is likely a life-threatening condition for them. HCWs
of younger age may have the professional responsibility to uptake and promote SIV. Still,
they may not perceive it as threatening to themselves, which may explain the reported
differences with the general population.
The overall low influenza vaccination uptake in this study is comparable to the
national rate reported in a previous recent survey [40] and similar to the European rate
(generally less than 30%) [7]. But it is lower than that reported for GPs in Greece [13] and
the 40.3% reported for nurses in Ireland [25].
In bivariate analyses, demographic factors associated with HCWs’ intention to receive
the influenza vaccination were male sex, older age, higher educational level, and being a
physician. Other studies have also suggested that male HCWs have a higher likelihood of
vaccine uptake [29]. In line with our results, similar studies [13,41,42] reported an increase
in vaccine coverage with age. It may be that older individuals consider themselves more
vulnerable to influenza complications, may have a positive experience of influenza vac-
cination from past years, and may feel a higher risk of severe health problems related to
influenza, leading them to be vaccinated. Physicians get a vaccine shot more frequently
than nurses, which aligns with many similar studies that could be explained mainly by
nurses’ fear of vaccine safety [43]. However, the profession did not exhibit any signifi-
cant association in the adjusted models. The Department of Work yielded no significant
correlation with any study variables concerning influenza vaccination uptake. However,
one would expect HCWs working in general internal medicine departments to be more
“sensitive” in receiving the vaccine due to numerous interactions with patients and their
relatives or HCWs working in ICUs to be alert since they treat patients with severe cases of
influenza [44].

5. Limitations and Strengths

Several limitations must be considered when interpreting the results of this study. The
cross-sectional research design does not permit any assumptions on causality. However, it
is logical that past behaviors affect current ones and that the initial intentions are translated
into behaviors and not vice versa. The questionnaires were self-administered, and thus
recall or social desirability bias cannot be excluded. However, this is the primary approach
to vaccine uptake research globally. The control tool beliefs subscale in the ‘TPB’ displayed
a Cronbach α of 0.63, somewhat lower than the recommended minimum of 0.70, and
this limitation should be noted as well. The study was conducted only in hospitals from
a northern prefecture in Greece, and thus the generalizability of the results beyond this
sample should be made with caution. Despite this, it is one of the first studies that tested
vaccination uptake based on behavior using the ‘TPB’ and the ‘CME’.
Vaccines 2023, 11, 1508 10 of 12

6. Conclusions
Numerous factors, including increased age, intention score, motivation for vaccination
(MoVac-flu) score, and the presence of chronic diseases, were associated with HCWs’
intention to get the seasonal influenza vaccination the last year and age, intention score,
and the presence of chronic diseases for every year. Interventions focused on the variables
identified in this study may be used to increase HCWs’ vaccination rates. This is an
essential addition to the current literature because it pinpoints that vaccination uptake is
simultaneously affected by logical cognitive processes and factors related to motivation
and empowerment in distinct self-regulatory domains such as value, impact, knowledge,
and autonomy. Future studies are required to assess the concept of vaccine literacy as an
important determinant in the choice to be vaccinated, as it might pull HCWs out of vaccine
hesitancy, thus increasing their engagement with vaccines.

Author Contributions: Conceptualization, T.B. and G.M.; Methodology, T.B. and P.G.; Writing—Original
Draft Preparation, T.B., G.M., G.K., S.K., P.L., P.G. and N.A.; Writing—Review and Editing, T.B., G.M.,
S.K. and N.A.; Funding acquisition S.K. and N.A.; Supervision T.B. All authors have read and agreed
to the published version of the manuscript.
Funding: This work was funded by Princess Nourah bint Abdulrahman University for project
number (PNURSP2023R347), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia.
Institutional Review Board Statement: Participation in the study was voluntary and has been
performed according to the ethical standards of the Declaration of Helsinki as revised in Brazil.
Informed consent was considered positive when participants returned the completed questionnaires.
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The data that support the findings of this study are available on request
from the corresponding author.
Acknowledgments: The researchers would like to thank the Deanship of Scientific Research, Princess
Nourah bint Abdulrahman University, for funding the publication of this project.
Conflicts of Interest: The authors declare no conflict of interest.

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