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Risk Compensation and Optimistic Bias: Why Healthcare Workers are Not Getting Vaccinated


By Jenna Tauber

Each year, approximately 5 percent to 20 percent of Americans get infected with the influenza virus.  With more than 200,000 hospitalizations each year for flu-related complications, it is a wonder that less than 50 percent of eligible citizens take preventive action by getting a flu shot (CDC, 2011b). Vaccination rates have been shown to vary greatly between age groups and demographics, but one particularly interesting cohort to examine is that of healthcare workers. Although these individuals have the most contact with at-risk patients and have a high probability of spreading the virus, they exhibit excessively low vaccination rates. In the 2010 to 2011 season, 36.5 percent of healthcare workers did not receive the influenza vaccine (CDC, 2011a).  Theories such as risk compensation and optimistic bias can be applied to analyze healthcare workers’ vaccination rates and can be utilized to develop and implement communication strategies that will better influence this group to get vaccinated.

The basic premise of Risk Compensation Theory is that when people feel safe, they take more risks to make up for it. According to Wood (2006), people strive toward achieving a “risk homeostasis” in which they work to maintain a target level of risk with which they are most comfortable.  A study on the effects of seat belt laws actually found that “drivers who feel safe may actually increase the risk that they pose to other drivers” (Bjerklie, 2006). Incidentally, this can be applied to the low rate of healthcare worker vaccinations. Healthcare workers’ perceptions of high safety result in greater risk behaviors—like not getting vaccinated—that consequently increase the risks they pose to the patients around them.

For obvious reasons, healthcare settings tend to have strict safety and sanitation standards that result in a sense of comfort and security for healthcare professionals and their patients. Rathert and May (2007) found that nurses working in a patient-centered atmosphere were more satisfied and felt more secure at work.  Although it is vital to foster this kind of environment, if left unchecked it may lead to some adverse effects.  If healthcare workers have a strong sense of comfort and security, they may have an inaccurate perception of how realistic their risks are of becoming infected with and spreading the flu and be more inclined to take greater risks when it comes to actively trying to protect themselves.

In a study by the National Foundation for Infection Diseases (2004) there was a large discrepancy between vaccinated and unvaccinated health care workers’ perceptions of their risk of getting the flu compared to the general public as well as their likelihood of spreading it to patients.  A major reason cited for not getting the vaccine was that the individual perceived a “low personal risk of contracting” the virus.  Additionally Clark, at al. (2009) found that both vaccinated and unvaccinated nurses believed the vaccination recommendation “was to protect their own health and to limit absenteeism” rather than to protect patients. Together, these elements culminate in inaccurate perceptions of risk that lead to workers in the field exhibiting higher risk behavior in the form of fewer vaccinations.

Somewhat comparable to risk compensation, optimistic bias happens when individuals compare themselves to an incorrect norm, causing them to believe they are below the average risk for an incident.  This idea of “unrealistic optimism” involves people believing negative things are more likely to happen to others, while positive things are more like to happen to them.  In considering who is at stake for a risk, an individual is likely to establish a stereotype is in his or her mind that he or she does not solely fit.  Therefore, this person is able to downplay the likelihood of being personally affected.  (McComas, 2011)

In terms of low vaccination rates, a large part of the issue is in the stereotype healthcare workers may have of those who get the flu. Having been medically educated to recognize that at-risk patients are generally above 65 or have another health condition, healthcare workers may have turned this kind of person into their prototype for a flu patient and thus for the kind of person who needs to be vaccinated.  This is significant, as research has shown that when an individual compares his or her chances of being exposed to a risk with another’s chances, the more similar the two are, the less likely the individual is to experience optimistic bias (McComas, 2011). Additionally, as individuals who tend to spend a majority of their time around less healthy patients, they may have a skewed view of what the average level of health is in the general public.  As medical workers, these individuals are then more likely to perceive themselves as above average health-wise and less in need of preventative action.

Once these elements are established, healthcare workers begin to experience unrealistic optimism. They are more likely to downplay their risks and give reasons to justify their behaviors, such as believing using sterile equipment and washing their hands is sufficient protection enough from flu acquisition and transmission, meaning remaining unvaccinated is acceptable.  They may also believe they have more control over a situation than they really do. It is possible that they will think that because they are healthcare professionals, they know better than others how not to get sick as they go about their day-to-day activities.

Putting these theories into practice, mandatory continuing education courses should be implemented to alter healthcare workers’ perceptions. Courses should provide a mixture of case studies and fact review to remind these workers of the real dangers of not getting vaccinated.  At the end, flu shots should either be offered or information about where they can be obtained should be given.

The material covered should account for what is known about Risk Compensation Theory and optimistic bias. Namely, it should target the misperception that healthcare workers are at a lower risk than others and try to break the stereotypical image that exists of who really needs the influenza vaccine. This course should include information reminding staff that although the people who are most at risk for flu-related complications are individuals over 65, residents of nursing homes, and those with heart conditions and diabetes, they themselves are at a high risk just by being in the settings they are in (Dash et al., 2004). They are the ones who have the most contact with high-risk patients and are thus the most likely to spread the virus. If these elements can be communicated, professionals will still be able to feel safe in their workplaces, but there will be caveats that help to balance perceptions of invincibility.

Of course, it is important to note that all communication theories have limitations. In a perfect universe, either of these theories could be made to apply exactly to each individual; however, this is not the case. It is possible that some health care workers do not get vaccinated because they are terrified of needles, while others may have an entirely different stereotype of an influenza victim, or none at all. None of these concepts can be used to exclusively describe or predict the behavior of all healthcare workers, but if some combination of them can be applied to a large enough sample within this cohort, these strategies may make a substantial difference.

The influenza virus is one that we are scientifically prepared to combat, but the rates of individual action have been low.  In particular, a large majority of healthcare workers—those who should be the most educated on the matter and who are most easily capable of spreading it en masse—do not tend to get vaccinated against the flu. By applying communication theories, one can infer that these workers may feel an exaggerated sense of security and that they are above average risk. This perspective can be altered by implementing new communication techniques in the form of continuing education classes that will influence healthcare workers to get vaccinated.

Jenna Tauber is communications director at Cornell University.

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Centers for Disease Control and Prevention (CDC). Influenza vaccination coverage among health-care personnel—United States, 2010-11 influenza season. Morbidity and  Mortality Weekly Report, 60(32), 1073-1077. 2011a.

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Clark SJ, Cowan AE and Wortley PM.  Influenza vaccination attitudes and  practices among US registered nurses. Am J Infect Control. 37(7), 551-556. September 2009.

Dash GP, Fauerbach L, Pfeiffer J, Soule B, Bartley J, Banard BM, Lundstrom T and Andrus  M. APIC position paper: Improving health care worker influenza immunization  rates. APIC Immunization Practices Working Group, 31(3), 123-125. May 2004.

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Rathert C and May DR. Healthcare work environments, employee satisfaction, and patient  safety: Care provider perspectives. Health Care Management Review. 32(1), 2-11. 2007.

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