http://orcid.org/0000-0003-2789-6655
Figures
Abstract
Background
In 2015 meningococcal group W was declared endemic in the UK, with the meningococcal ACWY vaccination (MenACWY) subsequently introduced amongst adolescents and first-year university students. This study aimed to determine MenACWY uptake amongst students and to evaluate how this was influenced by demographics and via the Health Belief Model (HBM).
Methods
This was a cross-sectional study conducted at a British university amongst first-year undergraduate students aged 18–25 years. Data collection was via an electronic questionnaire encompassing demographics, the HBM and vaccination status. Univariable analysis of the associations between demographics, health beliefs and vaccination was performed, followed by multiple logistic regression.
Results
401 participants were included in analysis. Vaccine uptake was 68.1%. Variables independently associated with vaccination upon multiple regression were age, gap-year, perceived effectiveness of the vaccine and knowledge about risk of meningitis. Compared to 18 year-olds, the odds of vaccination were reduced for 19 year-olds (aOR = 0.087, 95% CI = 0.010–0.729), 20 year-olds (aOR = 0.019, 95% CI = 0.002–0.161) and 21–25 year-olds (aOR = 0.003, 95% CI = <0.001–0.027). In contrast, taking a gap year (aOR = 2.939, 95% CI = 1.329–6.501), higher perceived vaccine effectiveness (aOR = 3.555, 95% CI = 1.787–7.073) and knowledge about meningitis risk (aOR = 2.481, 95% CI = 1.165–5.287) were independently associated with increased uptake.
Conclusions
MenACWY uptake amongst students in this study and in other sources is above the national coverage for all adolescents (35.3%), indicating that this vaccination programme may be increasing health inequalities. Older students are less likely to become vaccinated due to differing vaccination policy in this age-group. In future, strategies that focus on specific student cohorts and that highlight vaccine effectiveness and the risk of meningitis should be considered. National evaluation of this vaccination programme is recommended to clarify its impact on health inequalities.
Citation: Blagden S, Seddon D, Hungerford D, Stanistreet D (2017) Uptake of a new meningitis vaccination programme amongst first-year undergraduate students in the United Kingdom: A cross-sectional study. PLoS ONE 12(8): e0181817. https://doi.org/10.1371/journal.pone.0181817
Editor: Vladimir Brusic, Dana-Farber Cancer Institute, UNITED STATES
Received: June 8, 2017; Accepted: July 7, 2017; Published: August 2, 2017
Copyright: © 2017 Blagden et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The data in this study was collected via a survey from undergraduate students. As the study participants did not explicitly consent to their data being made available in a public repository, we have been advised by the University of Liverpool Research Data Management Team (rdm@liverpool.ac.uk) that it is not appropriate to make the data available in this format. However, data from this study ("Uptake of a new meningitis vaccination programme amongst first-year undergraduate students in the United Kingdom: A cross-sectional study") may be made available to other researchers who should contact the corresponding author Dr. Sarah Blagden via s.blagden@nhs.net.
Funding: The authors received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Since 2009 incidence of invasive meningococcal disease due to capsular group W (MenW) in the United Kingdom (UK) has been increasing [1,2]. Mortality has also increased, including, for the first time in the past decade, infant and adolescent deaths [2,3]. In early 2015, in light of accelerating incidence and mortality, MenW was declared endemic in the UK [1,2]. In response, the single-dose quadrivalent meningococcal ACWY (MenACWY) vaccine urgently replaced meningococcal C (MenC) vaccination in schools in 2015 and an urgent call/recall catch-up programme in primary care for children of school year 13 age (17–18 years-old) was implemented [3,4]. All students under 25 years of age attending university for the first time in Autumn 2015 were also recommended to become vaccinated [3].
This vaccination strategy reflects that adolescents and young adults have the highest carriage rates of meningococcal bacteria, with around 25% asymptomatically colonised [1,5]. Furthermore, young people, especially students, often live in close proximity in environments that facilitate bacterial transmission via droplet and aerosol routes [5]. These factors lead to this age-group experiencing the second highest rates of invasive meningococcal disease, after infants, in the population [5]. Furthermore, meningococcal carriage at this age drives transmission of MenW across the population, with the MenACWY vaccination programme anticipated to generate herd immunity [1].
In 2015, school-based vaccination of 13–15 year-olds began, whilst vaccination of students and of all young people aged 17–18 years was delivered in primary care [3,4]. Although UK students leaving school year 13 (aged 18 years) were amongst those actively invited for vaccination, this did not extend to older or international first-year students, where vaccination was limited to self-presenting individuals and opportunistic encounters [4].
As this is a new vaccination programme, there is very limited pre-existing research literature relating to its uptake. A recent study evaluated uptake of this vaccination programme at universities in Northern Ireland. Although it did not examine variables associated with vaccination, this study found that uptake varied from 87.3–90.7% amongst 18 year-old students and gradually fell with increasing age to 32.7–39.6% amongst 20–25 year old students [6]. In addition, another study evaluated uptake of the MenACWY vaccination at the University of Nottingham, UK following a mass campus vaccination campaign, which found that vaccine uptake was 71%, compared to 31% who had been vaccinated prior to arrival at university [7]. Crucially, however, this study identified that, even though all students were offered immediate free vaccination upon arrival at university, 43% of the unvaccinated population declined [7]. Thus, further work is essential to understand the factors that influence vaccination in this cohort. Four previous studies from the UK and United States (US) have also examined student uptake of meningococcal vaccines in the context of endemic MenC during the 1990s/early 2000s [8–11]. These reported vaccine uptake of between 51.0–87.0% and had examined several variables that affected vaccination, with factors such as age, university degree, gender and ethnicity significantly associated with vaccination in various studies [8–11].
The Health Belief Model (HBM) is a psychological behaviour change model which postulates that for somebody to access an intervention they must perceive that: they are susceptible to the disease, the disease is severe, the intervention would provide benefits and barriers would not be encountered [12,13]. Uptake may also be influenced by ‘cues to action’ and individual ‘self-efficacy’ [12,13]. Although not previously used within meningococcal vaccination, it has been widely used to understand student vaccination behaviour for other vaccinations such as influenza, measles and human papilloma virus (HPV) [14–23].
This study investigated MenACWY uptake amongst students at a UK university. As this is a new vaccination programme, research and evaluation are essential for several reasons. Firstly, although uptake data was collected by Public Health England (PHE) for children of school year 13 age, official estimates were complicated by the fact that students may receive vaccination at either their home or university GP practice. As there was no robust method for aligning these rates students registered at both their home and university GP practice may have appeared twice in the denominator. In addition, uptake data was not collected for older students. Therefore, this study will help to supplement official vaccination statistics. As discussed, this age-group has the highest meningococcal carriage rate and the second highest rate of invasive disease and it is essential to evaluate any attempt to address these public health concerns. This study is one of the first to evaluate this new vaccination programme and is the first to explore variables that are associated with uptake of this vaccination. This work contributes to wider evaluation of the vaccination programme and will help inform targeted MenACWY vaccination strategies, with the potential to also inform future strategies for other vaccines targeted at adolescents and young adults. Therefore, the study aimed to determine MenACWY uptake amongst first-year students and to ascertain how this was influenced by demographic characteristics and health beliefs. This aim was achieved.
Material and methods
Setting
This study was conducted at the University of Liverpool, UK. The university is situated in the centre of the city of Liverpool and serves a total population of 22,000 students, which included nearly 6,000 first-year undergraduate students in 2015/16 [24].
Participants
Inclusion criteria were in accordance with the MenACWY vaccination service specification, with participants required to be a first-year undergraduate student, aged 18–25 years and attending university for the first time in Autumn 2015 [4].
Study design and questionnaire
This was a community-based cross-sectional study that was conducted from March-May 2016 (questionnaire in S1 File). Data was collected via an electronic ‘SurveyMonkey’ questionnaire [25]. Throughout the survey, the term ‘meningitis’ was used instead of ‘invasive meningococcal disease’, for ease of reading and because it is a term that is more likely to be understood. The first item was a mandatory consent question that participants were required to accept in order to complete the survey summarising the study’s purpose, inclusion criteria, voluntary nature, confidentiality and right to withdraw. Confirmation was then sought that students were undertaking their first degree, and therefore met the eligibility criteria. Participants were next asked about their demographic characteristics, including their age, gender, ethnicity, university degree, home country and parental occupation (to determine socioeconomic group). Options for ethnicity were given in accordance with the 2015 Office for National Statistics (ONS) classification system for coding ethnicity in the UK [26].
Participants were subsequently asked yes/no items regarding experience of meningitis and MenACWY vaccination status. Participants were then directed to a HBM section depending on their vaccination status, as statements were phrased differently according to vaccination status. These items encompassed the following HBM domains: perceived severity, susceptibility, barriers, benefits and cues to action. Answers were given on a five-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). This section was based upon a previously validated instrument from a US study of pandemic influenza vaccination by Coe et al (2012) [17]. This tool was chosen because information was provided regarding its development and constituent items and because influenza, like meningococcal disease, is an acute infectious disease spread by droplet transmission that has experienced recent resurgences [17,27–29].
Some adjustments were made to the survey instrument. A question on vaccine cost was removed to reflect the free provision of UK healthcare and items pertaining to knowledge of meningitis and the impact of family and friends were incorporated to reflect evidence that these factors have previously influenced vaccination uptake [10,17,30,31]. In light of these amendments, further validation was undertaken. Twenty individuals piloted the questionnaire, with two items removed following this process. These related to loss of income following illness, which was considered irrelevant to most students and risk of death associated with vaccination, which was thought to pose potential anxieties and be inappropriate for an established vaccine. Cronbach’s alpha was then calculated for each HBM domain to evaluate the reliability and internal consistency of the instrument, with good internal consistency for most domains (Cronbach’s alpha = 0.494–0.813) (Table 1).
Upon survey completion students were directed to a leaflet that contained information about meningitis, the vaccine, the study and additional resources and contact details.
Sampling
Participants were recruited via email through University of Liverpool academic departments, followed by a reminder email two weeks later. All university departments with first-year undergraduate students enrolled were approached regarding study participation and those that agreed forwarded the survey via email to the first-year students in their department, encompassing around 3,000 students. A wide spectrum of degree programmes participated in the study.
Ethics
This project received ethical approval from the University of Liverpool Institute of Psychology Health Society Ethics Committee (approval number: IPHS-1516-LB-189). Informed valid consent was gained from study participants via the consent question at the beginning of the electronic questionnaire.
Analysis
All analyses were conducted using IBM SPSS statistics version 22. The first stage of analysis was data management. Where participants had only provided consent and/or demographic responses or had indicated they were not undertaking their first degree, they were excluded. Following this, available case analysis incorporating all participants who had responded to the variable(s) of interest was conducted. Several variables were recoded, with parental occupations recoded into the National Statistics Socio-economic Classification (NS-SEC) coding tool that is used to assign socio-economic analytical class based upon occupation in the UK [32]. Here, groups were further categorised into groups 1–4 and 5–8, which are often used to differentiate between advantaged and disadvantaged groups [32,33]. Undergraduate degrees were recoded into larger groups and, due to small counts for some ethnic minorities, ethnicity was recoded into “White British” and “Other ethnic groups”. In order to make HBM responses more meaningful, Likert scale responses 1–3 were re-categorised as “Disagree/neither agree nor disagree” and responses 4–5 as “Agree”. Age was treated as a categorical variable and sub-divided into four categories: 18 years, 19 years, 20 years and 21–25 years. This grouping of older students was used because in the UK students aged 21 years and above are classified as “mature students” [34].
For the sample overall, and for vaccinated and unvaccinated cohorts, summary statistics were calculated and tabulated. Univariable logistic regression was then undertaken to explore the association between independent variables (demographics and health beliefs) and the dependent variable (vaccination). Univariable associations were statistically significant if p≤0.05.
Finally, multiple logistic regression was used to investigate the effect of independent variables on vaccination, adjusted for the effect of confounders. Variables were entered into the multivariable model if, upon univariable regression analysis, the p value was ≤0.2. In addition, gender, age and ethnicity were entered into the model a priori. The goodness of fit and predictive properties of the multivariable model were assessed using the Chi-square value and the Nagelkerke R square value.
Results
Response rate
In total, 485 individuals responded to the survey, of which 57 (11.8%) had answered the consent statement only and a further 27 (5.6%) had provided either solely demographic responses and/or had indicated that this was not their first degree. These individuals were excluded. Therefore, the final sample contained 401 participants. As approximately 3,000 students had been forwarded the survey, this represents a crude response rate of 13.4%.
Vaccination uptake
Self-reported vaccination uptake was 68.1%, with 273 participants reporting that they had received the MenACWY vaccination and 128 reporting that they had not.
Sample characteristics
The median age of participants was 20 years and the majority were female (78.1%) (Table 2). The sample was mainly comprised of UK students (93.5%) and 28.9% of participants had taken a gap-year. Overall, 80% of the sample were White British. The sample was skewed towards more advantaged socio-economic groups (81.3%).
When considering health beliefs across the sample (Table 3), 89.3% of participants perceived that meningitis would cause severe disease if they were to become infected, although only 20.4% believed that it would cause death. In terms of susceptibility, although 69.6% believed they were at risk of getting meningitis, only 26.7% felt knowledgeable about their risk of meningitis. There was low perception of barriers to vaccination. In contrast, there was high perception of the general benefits of vaccination, with 75.3% believing vaccines prevent disease and 73.3% believing them to be safe. However, when considering the MenACWY vaccination specifically, only 55.4% perceived that it prevented meningitis. Doctor recommendation was a widely perceived cue to action, with 82.3% of participants believing themselves more likely to accept a vaccination if recommended by a doctor.
Univariable analysis
Age, international student status and university degree were associated with vaccination uptake (Table 2). Age was negatively associated with vaccination uptake, with the odds of vaccination reducing with increasing age. Similarly, international students were significantly less likely to become vaccinated. Compared to the degree cohort with the highest uptake, Medicine, students undertaking Arts, other vocational Health Sciences, Maths and Sciences and Psychology degrees had significantly reduced odds of vaccination.
Looking at the HBM (Table 3), students who believed meningitis would cause severe illness, who perceived themselves to be knowledgeable about their meningitis risk and who perceived that the MenACWY vaccine effectively prevents meningitis were more likely to become vaccinated. Students who believed vaccines to be safe were also more likely to become vaccinated, along with participants who were more likely to accept a vaccination if recommended by a pharmacist, nurse or friend/family member. In contrast, students who perceived that receiving MenACWY vaccination was inconvenient had reduced odds of vaccination.
Multivariable analysis
The multivariable model generated a large Chi-square statistic (170.340) and predicted vaccination significantly well (p<0.001). The Nagelkerke R square value of 0.556 demonstrated that 55.6% of the variability in vaccination was predicted by the multivariable model. Age was independently associated with vaccination, with, when compared to 18 year-olds, reduced odds of vaccination amongst 19 year-olds (adjusted odds ratio (aOR) = 0.087, 95% confidence interval (CI) = 0.010–0.729), 20 year-olds (aOR = 0.019, 95% CI = 0.002–0.161) and 21–25 year-olds (aOR = 0.003, 95% CI = <0.001–0.027). The other variables independently associated with vaccination were taking a gap-year (aOR = 2.939, 95% CI = 1.329–6.501), perceived knowledge about risk of meningitis (aOR = 2.481, 95% CI = 1.165–5.287) and perceived vaccine effectiveness (aOR = 3.555, 95% CI = 1.787–7.073) (Table 4).
Discussion
This is one of the first studies to evaluate the MenACWY vaccination programme in the UK and the first to explore variables associated with vaccination. We found that amongst study participants, MenACWY uptake was 68.1%. Data on vaccine uptake had not been routinely collected by the University of Liverpool, however in order to assess this figure’s representativeness, other data sources were examined. Amongst the school year 13 age-group that were actively called for vaccination, the national coverage reported by PHE was 35.2% [35]. Data provided by NHS England Cheshire and Merseyside of the Liverpool GP practices with large numbers of university students and data from the Student Wellbeing Department at Liverpool Hope University, another university in Liverpool, demonstrated vaccine uptake of between 40–68.6% [36]. The recent study by Moore et al in Northern Irish universities reported an uptake of between 32.7% and 90.7% depending on the age and sex of the students [6]. However, this study included some non-first time students who would not be eligible for vaccination and the uptake figures for older students may have underestimated uptake [6]. Turner et al reported 71% uptake of the MenACWY vaccination amongst first-years at the University of Nottingham following a campus-based mass vaccination campaign and the four previous studies of student meningococcal vaccination from the 1990s/2000s reported uptake of 51–87% [7–11].
Thus, although our study looked at a single university and is by no means representative of all UK students, it seems likely that student MenACWY vaccine uptake was closer to the figure reported in this study, above the national uptake and, therefore, above that of non-student adolescents. This may reflect the educational attainment of students as well as efforts by universities, GPs and organisations such as PHE to vaccinate students. For example, although the university did not routinely check the vaccination status of all new arrivals, the MenACWY vaccination was advertised heavily during “Welcome Week” at the University of Liverpool and drop-in vaccination sessions were provided on campus by the local GP practice to allow opportunistic vaccination of students. This is in line with the findings of Turner et al who demonstrated that offering vaccination upon immediate arrival at university increased uptake from 31% of students who had been vaccinated by their GP prior to arrival at university to 71% [7]. This higher student uptake, therefore, provides support for these efforts. Although students are at slightly increased risk of meningococcal disease due to living in close proximity to each other in environments such as halls of residence, non-students are more likely to come from disadvantaged backgrounds and live in deprived areas [37]. There is a considerable body of evidence suggesting that deprivation is linked to increased incidence of invasive meningococcal disease in the UK due to factors such as overcrowded living conditions and increased rates of smoking, including passive smoking, that increase the likelihood of both asymptomatic meningococcal carriage and invasive disease [38–42]. Thus, it is concerning that non-students do not have access to the efforts aimed at students and are likely to have experienced far lower vaccination uptake.
This study found that vaccination rates decreased with increasing age and has provided a unique insight into vaccination amongst 20–25 year-olds, with data on uptake in this age-group not collected by PHE [35]. This finding concurs with other studies of student meningococcal vaccination and is highly relevant given that many students enter university at an older age, with 50.4% of the sample aged 20–25 years [6,8,9]. As this association was amplified upon multivariable analysis, it is unlikely to be attributable to demographics or health beliefs. The key difference, therefore, between younger and older students was the difference in vaccination policy, with vaccination opportunistic amongst older students instead of active call/recall [4]. For GP practices and universities, this represents a focus for future vaccination efforts as younger students will increasingly receive vaccination in schools [3]. As with the likely lower vaccination uptake amongst non-students, further evaluation is needed to confirm this inequality in vaccination uptake and, if confirmed, to establish why this exists in order to prevent future vaccination programmes from perpetuating health inequalities.
An interesting finding was the positive association between vaccination and gap-year, despite univariable analysis suggesting a negative relationship. However, the fact that this was a self-reported variable and relied upon older students self-identifying as having taken a gap-year may have introduced confounding. An alternative explanation is that many students use their gap-year to travel to developing countries where MenACWY is a recommended travel vaccination [43].
Looking at the HBM, this study found that perceived effectiveness of MenACWY was significantly associated with uptake. This concurs with previous literature suggesting that a vaccine’s perceived ability to prevent disease is commonly the most important vaccination determinant [15,16,22,44–46]. Although in the minority in vaccinated and unvaccinated cohorts, students who perceived themselves as knowledgeable about their meningitis risk were significantly more likely to accept vaccination than those who did not. This finding supplements previous studies, whereby misconceptions about influenza, measles and HPV susceptibility were associated with vaccine rejection [15,20,44,46].
These findings represent potential focus areas in future vaccination campaigns. Such campaigns could target specific student groups, such as older students, and should include information on vaccine effectiveness and the risk of meningitis amongst students. As the literature has demonstrated that such factors may be relevant to other vaccinations, these findings could potentially inform strategies for other vaccinations in this age-group.
Strengths and limitations
This study was subject to several limitations inherent to cross-sectional studies. Firstly, the response rate of 13.4% indicates that response bias may have occurred, although this is likely to have been an underestimate due to the denominator used inevitably including students not eligible for vaccination; for example, those over 25 years-old. Furthermore, uptake may have been underestimated due to factors such as participants not being aware of what they were vaccinated against [31,47].
Demographic data obtained from the University of Liverpool demonstrated that 55% of first-year undergraduates in 2015/16 were female and 76.3% were White [48]. Thus, although the proportion of White students was fairly representative (80%), proportionally more females (78.1%) participated in the study. However, as we do not have the breakdown of each degree programme by gender, it is not possible to determine whether this female predominance was due to a response bias and an increased willingness of females to complete the survey or female dominance within participating departments.
The use of convenience sampling represents a further drawback and may have resulted in selection bias, with certain academic departments not participating in the study. Like response bias, this limits the generalisability of findings. Linked to this, the University of Liverpool is a highly prestigious university in the UK and its students may not be representative of the general population. It is noted, however, that similar uptake figures were obtained in the recent papers from Northern Ireland by Moore et al and the paper from the University of Nottingham by Turner et al, which increases the likelihood that the results from this study are representative of students and generalizable to the wider student population in the UK [6,7]. Although statistical techniques were used to adjust for confounding, some confounding introduced by response bias, selection bias and the sample taken from a single university is likely to remain. Whilst significant associations were identified, causality cannot be inferred and the mechanism behind associations may be unclear [49].
Although the HBM is a useful and widely accepted model by which to structure beliefs that influence vaccination, it is not all encompassing and it is probable that there will have been other predictors of vaccine uptake that were not examined in this study; for example, the HBM assumes that students are already aware of the vaccination programme, which may not be the case. Similarly, demographic factors that were not examined in this study, such as whether students lived in halls of residence or not, may also have influenced vaccination uptake. A further critique of the HBM is that, whilst it is able to identify factors associated with vaccination, it is not possible to determine the relative importance of each of these factors in influencing vaccination.
In terms of strengths, this is one of the first studies to evaluate the MenACWY vaccination programme in the UK and the first to comprehensively evaluate variables associated with its uptake via multivariable analysis and a validated framework such as the HBM. The dependent variable was actual vaccination instead of intended uptake, which, with intentions not always translating into behaviour, is more meaningful when addressing behaviour. Furthermore, unlike other studies, data collection was undertaken when the year’s vaccination programme was complete to allow accurate determination of uptake. A large number of students participated, providing a considerable number of individuals at high-risk of meningitis due to their age and student status. The use of multivariable regression was a key strength as it allowed adjustment for confounders, with similar studies not utilising this technique [6,7,10,11]. The use of regression analysis enabled variables to be identified that were significantly associated with MenACWY vaccination in the UK, with the potential to inform future targeted vaccination strategies.
Conclusions
This study’s findings suggest that there may be inequalities in MenACWY vaccine uptake, which warrant further evaluation and research, with potential implications for future policy if confirmed. Younger students and gap-year students were more likely to receive vaccination. Vaccination uptake was also affected by health beliefs, with students more likely to become vaccinated if they perceived the vaccine to be effective and if they were knowledgeable about their risk of meningitis. These health beliefs and demographic associations should be considered in future vaccination campaigns and additional research is recommended to explore them further.
Acknowledgments
We would like to thank Dr Dan Pope and Dr Jennie Day for their assistance over the course of this study and the University of Liverpool academic departments that enabled dissemination of the study questionnaire. Most importantly, we would like to thank all of the students who participated in this study.
References
- 1.
Joint Committee on Vaccination and Immunisation. Minute of the meeting on 4 February 2015. 13 March 2015. Available at: https://app.box.com/s/iddfb4ppwkmtjusir2tc/1/2199012147/27417264008/1?&_suid=142919726006507841764942240252. (Accessed 20 June 2016).
- 2.
Public Health England. Continuing increase in meningococcal group W (MenW) disease in England. Health Protection Report 2015. 27 February 2015. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/407865/hpr0715_men-w.pdf (Accessed 12 August 2016).
- 3.
Public Health England. Meningococcal ACWY conjugate vaccination (MenACWY). Public Health England Letter to General Practitioners and CCGs 2015. 22nd June 2015. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/437901/150622_ACWY_bipartite_letter.pdf. (Accessed 12 August 2016).
- 4.
NHS England. Enhanced services specification: Meningococcal freshers vaccination programme 2016/17. March 2016. Available at: https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/04/Menfreshers-2016-17.pdf. (Accessed June 20 2016).
- 5.
Department of Health. The Green Book. Chapter 22: Meningococcal. September 2015. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/462629/2904512_Green_Book_Chapter_22_v6_0W.PDF. (Accessed 20 June 2016).
- 6. Moore PJ, Millar BC, Moore JE. Meningococcal ACWY vaccine uptake and awareness among student freshers enrolled at Northern Ireland universities. Int J Adolesc Med Health 2017.
- 7. Turner DP, Oldfield NJ, Bayliss CD. University vaccine campaign increases meningococcal ACWY vaccine coverage. Public Health 2017.
- 8. Paneth N, Kort EJ, Jurczak D, Havlichek DA Jr, Braunlich K, Moorer G, et al. Predictors of Vaccination Rates During a Mass Meningococcal Vaccination Program on a College Campus. J Am Coll Health 2000;49(1):7–11. pmid:10967878
- 9. Roberts CL, Roome A, Algert CS, Walsh SJ, Kurland M, Lawless K, et al. A meningococcal vaccination campaign on a university campus: vaccination rates and factors in nonparticipation. Am J Public Health 1996;86(8):1155–1158. pmid:8712279
- 10. Thirlaway K, Lukman H. Meningitis C vaccine uptake by British undergraduates. Commun Dis Public Health 2003;6(2):157–160. pmid:12889298
- 11. Edmunds MR, Davison JE, Wood AL, Raichura V. Few university students from overseas have been vaccinated against meningococcal infection. BMJ 2001;322(7278):102.
- 12. Rosenstock IM. Historical origins of the health belief model. Health Education & Behavior 1974;2(4):328–335.
- 13. Rosenstock IM, Strecher VJ, Becker MH. Social learning theory and the health belief model. Health Educ Behav 1988;15(2):175–183.
- 14. Lin WC, Ball C. Factors affecting the decision of nursing students in Taiwan to be vaccinated against hepatitis B infection. J Adv Nurs 1997;25(4):709–718. pmid:9104666
- 15. Krawczyk AL, Perez S, Lau E, Holcroft CA, Amsel R, Knäuper B, et al. Human papillomavirus vaccination intentions and uptake in college women. Health Psychology 2012 09;31(5):685–693. pmid:22268713
- 16. Bennett KK, Buchanan JA, Adams AD. Social-cognitive predictors of intention to vaccinate against the human papillomavirus in college-age women. J Soc Psychol 2012;152(4):480–492. pmid:22822686
- 17. Coe AB, Gatewood SB, Moczygemba LR, Goode JV, Beckner JO. The use of the health belief model to assess predictors of intent to receive the novel (2009) H1N1 influenza vaccine. Inov Pharm 2012;3(2):1–11. pmid:22844651
- 18. Donadiki EM, Jimenez-Garcia R, Hernandez-Barrera V, Sourtzi P, Carrasco-Garrido P, Lopez de Andres A, et al. Health Belief Model applied to non-compliance with HPV vaccine among female university students. Public Health 2014;128(3):268–273. pmid:24529635
- 19. Liau A, Zimet GD, Liau A, Zimet GD, Liau A, Zimet GD, et al. Undergraduates' perception of HIV immunization: attitudes and behaviours as determining factors. Int J STD AIDS 2000;11(7):445–450. pmid:10919486
- 20. Pielak KL, Hilton A. University students immunized and not immunized for measles: A comparison of beliefs, attitudes, and perceived barriers and benefits. Can J Public Health 2003;94(3):193–196. pmid:12790493
- 21. Richards K. College men and women and their intent to receive genital human papillomavirus vaccine. SAGE Open Med 2016;6(1).
- 22. Sundstrom B, Carr LA, DeMaria AL, Korte JE, Modesitt SC, Pierce JY, et al. Protecting the Next Generation: Elaborating the Health Belief Model to Increase HPV Vaccination Among College-Age Women. Soc Mark Quar 2015;21(3):173–188.
- 23. Wheldon CW, Buhi ER, Daley EM. Gay and bisexual men's human papillomavirus vaccine intentions: a theory-based structural equation analysis. J Health Psychol;18(9):1177–1186. pmid:23129831
- 24.
University of Liverpool. About the University. 2016. Available at: https://www.liverpool.ac.uk/about/. (Accessed 2 October 2016).
- 25.
SurveyMonkey. SurveyMonkey: Free online survey software & questionnaire tool. 2016. Available at: https://www.surveymonkey.com. (Accessed 7 October 2016).
- 26.
Office for National Statistics. Ethnic Group. 6 January 2016. Available at: http://webarchive.nationalarchives.gov.uk/20160105160709/http://www.ons.gov.uk/ons/guide-method/measuring-equality/equality/ethnic-nat-identity-religion/ethnic-group/index.html. (Accessed 21st November 2016).
- 27.
Department of Health. The Green Book. Chapter 19. Influenza. August 2015. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/456568/2904394_Green_Book_Chapter_19_v10_0.pdf. (Accessed 2 January 2016).
- 28. Dawood FS, Iuliano AD, Reed C, Meltzer MI, Shay DK, Cheng P, et al. Estimated global mortality associated with the first 12 months of 2009 pandemic influenza A H1N1 virus circulation: a modelling study. Lancet Infect Dis 2012;12(9):687–695. pmid:22738893
- 29. Zhang G, Xia Z, Liu Y, Li X, Tan X, Tian Y, et al. Epidemiological and clinical features of 308 hospitalized patients with novel 2009 influenza A (H1N1) virus infection in China during the first pandemic wave. Intervirology 2011;54(3):164–170. pmid:21051903
- 30. Goodman AL, Masuet-Aumatell C, Halbert J, Zuckerman JN. Awareness of meningococcal disease among travelers from the United Kingdom to the meningitis belt in Africa. Am J Trop Med Hyg 2014;91(2):281–286. pmid:24891461
- 31. Le Ngoc Tho S, Ader F, Ferry T, Floret D, Arnal M, Fargeas S, et al. Vaccination against serogroup B Neisseria meningitidis: Perceptions and attitudes of parents. Vaccine 2015;33(30):3463–3470. pmid:26055293
- 32.
Office for National Statistics. SOC2010 volume 3: the National Statistics Socio-economic classification (NS-SEC rebased on SOC2010). 2016. Available at: http://webarchive.nationalarchives.gov.uk/20160105160709/http://www.ons.gov.uk/ons/guide-method/classifications/current-standard-classifications/soc2010/soc2010-volume-3-ns-sec—rebased-on-soc2010—user-manual/index.html. (Accessed 15 June 2016).
- 33.
The Deputy Prime Minister's Office. Research and analysis. Social mobility indicators. 25 March 2015. Available at: https://www.gov.uk/government/publications/social-mobility-indicators/social-mobility-indicators. (Accessed 21 July 2016).
- 34.
UCAS. Mature undergraduate students. 2017. Available at: https://www.ucas.com/ucas/undergraduate/getting-started/mature-undergraduate-students. (Accessed 25 May 2017).
- 35.
Public Health England. Vaccine coverage estimate for the first urgent catch-up meningococcal ACWY (MenACWY) immunisation programme for England, updated to the end of March 2016. 26 May 2016. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/526220/hpr1816_menACWY.pdf. (Accessed 19 July 2016).
- 36.
ImmForm. Meningtis data collection. Report date: 15/7/16. Access provided by NHS England Cheshire and Merseyside. 15 July 2016. Available at: https://portal.immform.dh.gov.uk/. (Accessed 15 July 2016).
- 37.
Department for Business, Skills and Innovation. BIS Research Paper No. 186: Socioeconomic, ethnic and gender differences in HE participation. November 2015; Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/474273/BIS-15-85-socio-economic-ethnic-and-gender-differences.pdf. Accessed 7 October, 2016.
- 38. Williams CJ, Willocks LJ, Lake IR, Hunter PR. Geographic correlation between deprivation and risk of meningococcal disease: an ecological study. BMC Public Health 2004 26;4:30. pmid:15274745
- 39. Stuart JM, Middleton N, Gunnell DJ. Socioeconomic inequality and meningococcal disease. Commun Dis Public Health 2002;5(4):327–328. pmid:12564252
- 40. Fone DL, Harries J, Lester N, Nehaul L. Meningococcal disease and social deprivation: a small area geographical study in Gwent, UK. Epidemiol Infect 2003;130(01):53–58.
- 41. Heyderman RS, Ben-Shlomo Y, Brennan CA, Somerset M. The incidence and mortality for meningococcal disease associated with area deprivation: an ecological study of hospital episode statistics. Arch Dis Child 2004;89(11):1064–1068. pmid:15499066
- 42. Jones IR, Urwin G, Feldman RA, Banatvala N. Social deprivation and bacterial meningitis in north east Thames region: three year study using small area statistics. BMJ 1997;314(7083):794–795. pmid:9080999
- 43.
NHS Choices. Travel vaccinations. 16 November 2015. Available at: http://www.nhs.uk/Conditions/Travel-immunisation/Pages/Immunisations.aspx#meningitis. (Accessed 28 July 2016).
- 44. Matsui D, Shigeta M, Ozasa K, Kuriyama N, Watanabe I, Watanabe Y, et al. Factors associated with influenza vaccination status of residents of a rural community in Japan. BMC Public Health 2011 Jan-1;11(1):149.
- 45. Painter JE, Sales JM, Pazol K, Wingood GM, Windle M, Orenstein WA, et al. Adolescent attitudes toward influenza vaccination and vaccine uptake in a school-based influenza vaccination intervention: A mediation analysis. J Sch Health 2011;81(6):304–312. pmid:21592125
- 46. Yang ZJ. Predicting young adults' intentions to get the H1N1 vaccine: an integrated model. J Health Commun 2015;20(1):69–79. pmid:24870976
- 47. Al-Khashan HI, Selim MA, Mishriky AM, Binsaeed AA. Meningitis and seasonal influenza vaccination coverage among military personnel in central Saudi Arabia. Saudi Med J 2011;32(2):159–165. pmid:21301763
- 48.
University of Liverpool Student Administration Department. Personal communication regarding student demographic data. 15 August 2016.
- 49. Levin KA. Study design III: Cross-sectional studies. Evid Based Dent 2006;7(1):24–25. pmid:16557257