Promoting influenza prevention for elderly people in Hong Kong using health action process approach: study protocol

Seasonal influenza can cause mild to severe illness, or even death. Each year, approximately 1 million deaths worldwide are estimated to be related to influenza [1]. According to the American Center for Disease Control and Prevention [2], certain groups of people, such as children under five, elderly people aged over 65, pregnant women, and people with certain chronic medical conditions, are at high risk of seasonal flu-related complications. It has been reported that Hong Kong elderly people (age above 65) are 14 times more likely than midlife adults (age between 40 and 65) to die from influenza [1]. Based on an assessment of weekly hospitalization counts in Hong Kong during 1996 to 2000, influenza was revealed to be significantly associated with hospitalization for acute respiratory disease, with large and noticeable rates of excess hospitalization for elderly people aged above 65 [3]. In peak influenza season, these individuals are more vulnerable to influenza. As such, elderly people are an ‘at risk’ population, given the fact that the population is, in general, aging and is going to increase massively in the future. This leads to the prevention of illness in this population a priority for governments, otherwise it’s going to cost health services a massive amount. To prevent infection with seasonal flu, people are advised to maintain some key prevention behaviors, such as wearing facemasks in enclosed public spaces, hand washing, using antibacterial sanitizers, or to consider having an influenza vaccination [4].

According to the concept of bounded rationality [5], individuals in influenza pandemic make decisions on health care and medication using heuristics, or rules based on past experiences and information instead of using rational decisions. Therefore, it is necessary to provide individuals a theory and evidence-based intervention to guide them form rational decisions when facing an influenza pandemic. Research adopting social psychological theories in influenza prevention has generally focused on influenza vaccination behaviors examining perceived severity, perceived barriers, perceived susceptibility, and perceived benefits, as well as social norms, intentions, worries and regrets towards vaccinations [6–11]. There are several theoretical models to explain the decisions and behaviors on influenza vaccination. For example, the health belief model [12] examines individuals’ perceptions and attitudes towards illnesses or health compromising behaviors in terms of three facets: individual perceptions (i.e., perceived susceptibility and perceived severity), modifying factors (i.e., perceived threat, environmental factors, and cues to action), and likelihood of action (i.e., perceived benefits and perceived barriers). Previous studies have provided initial support for the predictive value of these facets on individuals’ acceptance of influenza vaccination [6, 10]. Yet, the risk perception alone cannot fully explain preventive behaviors without considering the influence of outcome expectations and social norms, namely, social pressure of a normative status. The theory of planned behavior [13], on the other hand, explains the influences of individuals’ attitudes, subjective norms, and perceived behavioral control on the intentions and behaviors of influenza prevention. Intention is viewed as the most proximal determinant of individuals’ volitional behaviors. Research has preliminarily demonstrated significant associations between these beliefs and intentions to receive the influenza vaccine, which in turn predicted vaccination behaviors [9]; while non-intention to vaccination is significantly related to disbelief in the efficacy of, and negative attitudes toward vaccination as well as lack of perceived threat [7].

Although vaccination is an ideal way to prevent all types of influenza, numerous serotypes and the high variability of the influenza virus still challenge the uptake of influenza vaccines. In addition, everyday preventive actions, such as washing hands, avoid touching eyes, nose or mouth, and facemask wearing also play a very important role in prevention. Moreover, the relationship between vaccination and other influenza preventive behaviors (e.g., personal hygiene practices) is still unknown. Regarding as one of the main factors contributing to the transmission of influenza within the community, low behavioral compliance to these recommended health actions are frequently reported [14] and this might be explained as acceptance of vaccination accidently warrant people a false information/belief of free of being infected, which further causing them to lower their behavioral compliance. Nonetheless, researchers have begun to investigate the psychological factors associated with the lack of behavioral compliance toward influenza prevention [6, 15]. For example, consistent with the health belief model, the reason people fail to, or refrain from, wearing facemasks might be due to a lack of perceived susceptibility, cues to action, and perceived benefits, rather than lack of perceived severity and perceived barriers [15].

Although both the health belief model and theory of planned behavior could somewhat explain the complex cognitive interactions in influenza prevention, the factors of post-intentional volitional stage have been inadequately addressed which play an important role in the maintenance of preventive behaviors. Although the motivational paths to intentions have been well-established with large effect sizes, the prediction from intention to health behaviors always fail, a phenomenon called “the intention-behavior gap” [16]. Based on the model of action phases [17] and social-cognitive theory [18], the health action process approach (HAPA) [16] was developed by integrating these two theoretical approaches. The HAPA stipulates a two-phase approach to action, a motivational phase and an implemental or ‘planning’ phase. Motivation is considered a necessary but not sufficient condition for action initiation and persistence; people also need to identify effective plans to enact their intentions or motives. Interventions should, therefore, target both motivational and implemental phases [19]. In other words, it suggests a distinction between (a) pre-intentional motivational processes that lead to a behavioral intention, and (b) post-intentional process that lead to actual health-related behavior. The HAPA is, therefore, an appropriate approach to explain the processes that lead to motivated behavior and its enactment in health contexts, including the influenza vaccination behaviors [20]. It has also been demonstrated applicable in the local context of Hong Kong for other health-related behaviors such as the condom use for men who have sex with men [21].

The current project therefore will develop a HAPA-based intervention to promote influenza prevention behaviors in Hong Kong older adults. In order to promote the initiation and maintenance of influenza prevention behaviors, it will comprise intervention components targeting both motivation and planning. In the behavior initiation stage, three key psychological variables have been associated with increased motivation toward influenza prevention: risk perception, action self-efficacy, and outcome expectancy. The intervention components that have been shown to target and effect change in each of these variables are information provision (risk perception, action self-efficacy, and positive outcome expectancy), goal setting (action self-efficacy), and mental simulations (positive outcome expectancy). In the behavior maintenance stage, different strategies will be used which include the maintenance/relapse prevention self-efficacy, coping planning, and maintaining the satisfaction and enjoyment of the behavior change. The components targeting increased planning are action plans or implementation intentions [19]. Comparing to the behavior initiation stage which focuses on approaching a more favorable health stage, the maintenance stage help participants avoid reverting to a less favorable non-intending status [22].

As a subtropical city, Hong Kong is located at the hypothetical epicenter of influenza pandemics [1, 3]. Despite the widespread influenza prevention measures suggested by various national and regional centers for disease control and prevention, relatively little research has been done to promote the adoption of preventive behaviors based on the psychosocial theories, as compared to the basic research for vaccination development and large-scale telephone interviews [14, 15]. Although vaccination is the most effective way of preventing influenza and much existing research focuses on the influence of psychosocial variables for vaccination rather than daily protective measures, effective daily preventive measures are also important [4]. Most importantly, even the vaccination is not able to guarantee full protection from influenza. Therefore, the current 24-month project aimed to develop a theory-based intervention materials for influenza prevention behaviors and examine its effectiveness in a sample of Hong Kong elderly people. Particular emphasis will be on the emphasis on both the initiation and maintenance of influenza prevention behaviors [17].

The key benefit of the current research will be development and application of theory-based intervention materials to promote influenza prevention of Hong Kong older adults. The materials developed for the current project will supplement and extend existing educational materials such as those available from the Centre for Health Protection of Hong Kong, which largely focus on the provision of information rather than how to help older adults to initiate and maintain the influenza prevention behaviors. The impact of the project findings will be maximized by dissemination to key academic, policy, and practitioner groups.