Intention to B Vaccinate: Evidence from Migrant Workers in Tianjin,

Cai Liu Tianjin University of Traditional Chinese Stephen Nicholas Guangdong University of Forgien studies Wang Jian (  [email protected] ) Wuhan University https://orcid.org/0000-0001-9539-2016

Research article

Keywords: Migrant workers, intention, Protection Motivation Theory, Health education

Posted Date: May 11th, 2020

DOI: https://doi.org/10.21203/rs.3.rs-24197/v1

License:   This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License

Version of Record: A version of this preprint was published on August 10th, 2020. See the published version at https://doi.org/10.1186/s12889-020-09292-2.

Page 1/20 Abstract

Background: Migrant workers are a susceptible population to the and a vulnerablespot in China’s procedures. There is no free HB immunization program for migrant workers in China, so understanding migrant workers’ motivation to receive the is the frst step in designing effect immunization policies.

Method: A cross-sectional study was carried out in three migrant-dense industries in Tianjin, China. Our sample consisted of 406 migrant workers, 133 from the retail industry, 119 from the manufacturing industry, and 154 from the service industry. Protection motivation theory (PMT) factors were produced by principal component factor analysis. Socio-demographic variables, migration-industry variablesand PMT factors were estimated in a step-by-step binary logistic regression model to explore migrant workers intention to vaccinate.

Results: The nested binary logistic regression model results suggested that the severity factor, self- efcacy factor and response cost factor from the PMT constructs were the three statistically signifcant factors (p<0.05) that affect the migrant workers vaccination intention. The severity factor and self- efcacy factor to HB vaccination were positively related to HB vaccination intention (OR=1.500, OR=1.631) while the response cost was negatively related to motivation to take HB vaccine (OR=0.626). The socio-demographic variables showed that younger, married and good self-rated health status participants were statistically associated with the intention of taking the HB vaccine. Sex, education level and income group were not signifcantly associated with vaccination intentions. The migration-industry variables show that migrant location had astrong effect on migrant workers’ vaccination intention.

Conclusions: Applying integrated PMT constructs to the vaccination intention of Tianjin’s migrant population provide new insights into migrant workers’ intention to the HB vaccinate. Our fndings suggest specifc recommendations on health education and immunization management policies for migrant workers.

Background

The spread of infectious poses serious issues, especially in China. While the 2002–2003 severe acute respiratory syndrome (SARS) and the 2019–2020 COVID-19 have attracted world-wide attention, the (HBV) is ranked frst among class A and B statutory reported infectious diseases in China [1]. Over the past decade, China’s National Notifable Diseases Reporting System (NNDRS) notifed 60–80,000 acute hepatitis B cases each year, most of them among adults [2]. The routine immunization for in 1992, and a 2009 catch-up campaign for children born between 1994–2001, signifcantly decreased the vertical transmission hepatitis B in under 15 year olds [3]. An ongoing challenge is the increasing rate of horizontal HBV in adults. The highest incidence is among 20–29 year olds, which is also the most prevalent age of China’s migrant workers [4]. With China’s rapid urbanization, migrant workers reached 288 million in 2018, accounting for more than one third of

Page 2/20 the entire working population [5]. With the HBV transmission route running through poor living conditions and high geographical mobility, migrant workers are a highly susceptible transmitter-recipient HBV population and a vulnerable spot in China’s immunization procedures [6–8].

The HB vaccine is the most economical and effective way to prevent HBV infection and its spread among adults [9 10]. Previous studies have shown that the intention to receive the HBV vaccine is affected by individual’s knowledge of HBV and the HB vaccine [11 12]. Research showed that migrant workers have poorer cognition of HBV and the HB vaccine, and a higher HBV prevalence rate, than permanent workers due to their poorer education and health awareness levels, living in groups and lower accessibility to [13–16]. Previous Chinese studies have also identifed an individual’s knowledge and cognition of HB and the HB vaccine as key factors explaining HB vaccination behavior, but these studies only employed partial measures of HBV cognition [17–19 ].

One exception was a study using protection motivation theory (PMT) to specify and test a cognition model of migrant workers’ HBV behavior, but the migration-industry variables characteristics, health related behavior or intentions and response costs were excluded from the model [20]. Addressing these limitations, this paper applies a full PMT model, including migration-industry variables, health related behavior or intentions and response costs, to explain HBV behaviour in a high migration region, Tianjin, and in three industry sectors (manufacturing, retail and services), with a high proportion of migrant workers.

Tianjin provides a unique region for the study of migrant HB vaccination behavior and for developing strategies to prevent and treat hepatitis for susceptible and high-risk migrant populations [21]. In 2014, the Beijing-Tianjin-Hebei regional development strategy specifed Tianjin’s Binhai new district as the main platform for the transfer of industry and non-capital functions from Beijing, which saw Tianjin’s migrant population grow at 12%-15% each year [22]. By 2018, 5 million migrants accounted for 32% of Tianjin's population and a signifcant proportion of Tianjin’s workforce [23]. Besides having a poorer cognition of HBV and the benefts of the HB vaccine, Tianjin’s migrant workers were excluded from the free 2018 vaccination program for local workers in close contact with HB [24]. Migrant workers faced a cost-beneft calculation on whether to pay for the HB vaccine or not vaccinate. Our model includes Tianjin migrant workers’ response cost motivation to pay voluntarily for the HBV vaccine. Second, our model includes migration-industry variables, specifcally migrant area, whether migrants were accompanied or not by other family members and industry sector. Finally, our model includes health related behavior or intentions, mainly worker cognition, risk perceptions and likelihood to follow others in vaccination intention and HBV. We apply protection motivation theory to answer the following questions: What was the intention of Tianjin migrant workers to receive the HBV vaccination?; How did Tianjin migrant workers assess the cost-beneft calculation of paying for the HBV vaccine?; and How can migrant workers intentions to receive the HBV vaccine be improved? The answer to these questions can improve HBV vaccination policy in Tianjin and China.

Page 3/20 PMT is a widely used and powerful theoretical framework for assessing how individuals are motivated to react in a self-protective way towards a perceived health threat, which has informed public health issues in practice, especially implementing targeted health intervention strategies [25 26]. As set out in Fig. 1, PMT divides individual cognition into three parts [27 28]: information source (derived from individual and environmental characteristics), threat appraisal (severity and susceptibility) and coping appraisal (response efcacy, self-efcacy and response costs). Severity refers to the individual's subjective perception of the severity of a [28]. Vulnerability refers to an individual's cognition of the likelihood of getting sick, related to an individual’s perception of the probability of being infected by HBV [28]. For instance, knowing an infected person in the village or having a family history of HBV. Response- efcacy refers to the individual's perceived effectiveness of protective behavior in preventing and controlling the HBV threat [28]. In this study, response-efcacy is the individual's awareness of the HB vaccine’s effectiveness in preventing HBV infection. Self-efcacy is the individual's ability to take protective action [28]. Response costs are the barriers to taking protective behaviour [28], mainly the price the individual would pay for protective behavior, measured by the cost of the HB vaccine, extent of HB vaccination knowledge and worries about the side effects of the vaccine. Generally, the higher the individual's perception on severity, vulnerability, response-efcacy and self-efcacy, the more likely protective behaviour is taken, while response cost hinders protective motivation or behavior.

Methods Study site and population

Selecting three industry sectors, we surveyed migrant workers who had lived for six months in Binhai New District in Tianjin, but did not possess a Binhai New District household registration card or hukou. We divided migrants into Tianjin migrants, with a non-Binhai New District, but a Tianjin hukou, and non- Tianjin migrants, with a non-Binhai New District and non-Tianjin hukou. Migrants accounted for about 60% of the Binhai New District population in 2017. Given the high mobility and the lack of registration of migrants, sampling migrant worker “hidden populations” is difcult [29]. Employing the convenience sampling method used in previous studies of migrant children’s immunization in Beijing, between July and October in 2017 we drew samples from manufacturing, retail and services, which were densely population by migrants [30 31]. Data collection

In order to train Tianjin University of Traditional Chinese Medicine research assistants and test the questionnaire for its comprehension, a pilot survey was performed before starting the feld survey. Research assistants were instructed on how to assist migrant workers whose education might limit their ability to understand and complete the survey. In the face-to-face interviews, all the participants were volunteers and informed about their rights not answer questions. Since we did not survey the infection status or collect any biological samples, Tianjin University of Traditional Chinese Medicine did not request medical and health research ethics approval. Except those who clearly claimed that they have

Page 4/20 already been vaccinated before, data were obtained on 406 migrant workers, comprising 133 workers from the manufacturing, 119 from retail, and 154 from service industries. Measures

Dependent variable- intention to take HB vaccine: The intention to take the HB vaccine was measured by a self-report question: “Will you take the HB vaccine in the future?” with a binary yes or no response. The mean response to taking the HB vaccine was 0.672. PMT variables: The questionnaire included questions based on PMT variables in Fig. 1, workers’ vaccination history and migrant-industry characteristics. Based on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) Table 1 displays the PMT variables. The severity of HB was measured by the clinical symptoms, the costs for the individual and their family and social discrimination. Vulnerability refers to the migrant’s perceived infection probability compared with local workers. Similar to previous studies, response efcacy was measured by the safety and effectiveness of the vaccine. Migrant workers’ self-efcacy was measured by the advice of nearby people, the work organization, family, friends or a doctor to vaccinate [32]. Response costs are the barriers facing the individual to adopt the protective behavior, measured by the vaccination information and worries about the side effects of the vaccine, and the price of protective behavior, measured by the cost of the HB vaccine.

Page 5/20 Table 1 PMT constructs and factor analysis (N = 406) Factors and Items loading Variance Cronbach’s alpha

F1-Severity factor 4.156 0.876

HB is incurable. 0.560

It is expensive to cure HB. 0.660

The symptom of HB is unbearable. 0.829

HB would bring huge mental stress for the family. 0.842

HB patients and HBV carrier would suffer from social 0.697 discrimination.

F2-Self efcacy factor 2.819 0.873

I would like to take HB vaccine if people around me mostly 0.833 choose to.

I would like to take HB vaccine if it is organized by the work 0.847 place.

I would like to take HB vaccine if the family and friends 0.779 recommend that.

I would like to take HB vaccine if the doctor advice that. 0.628

F3-Response efcacy factor 1.854 0.837

HB vaccine is developed enough for common use. 0.726

Taking vaccine is an effective way to prevent HBV. 0.750

F4-Vulnerabality factor 1.240 0.806

As the migrant, the risk to get HBV infected is higher than other 0.605 population.

People around me get HBV infected are more than before. 0.625

F5-response cost factor 1.137 0.611

It is inconvenient for me to take HB vaccine. 0.556

I do not have enough information to take HB vaccine. 0.477

The side effect is serious when taking HB vaccine. 0.646

Cumulative(%) 87.13

Control variables: Table 2 presents the control variables. We assessed two main categories of other factors that would affect migrant workers’ vaccine intention: socio-demographic characteristics and

Page 6/20 migration-industry characteristics. Socio-demographic characteristics included age, sex, education level, marital status, self-rated health and income group. Age was treated as continuous variable; education level was divided into 3 groups: low (below senior high school), medium (senior high school or equivalent) and high (above and senior high school). The income group variable was based on tertiles of the respondent’s average monthly income. Migration-industry characteristics included non-Tianjin migrant or Tianjin migrant; whether the migrant was accompanied by family or not; and industry group (manufacturing, retail and services).

Page 7/20 Table 2 Migrant worker socio-demographic and migration-industry variables defnition and descriptive statistics (N = 406) Variable Properties and Variable defnitions Mean(± sd)

Dependent variable

Vaccination 1 if take HB vaccine in the future; .672 intention 0 otherwise .328

Independent variables

Socio-demographic characteristics

Age Migrant age (16 ~ 65) 37.631 ± 12.750

Sex 1 if male 0.483

0 if female 0.517

Education

>Senior high school, if years of schooling are higher than 9 years 0.537

Marital status 1 if married 0.768

0 if unmarried, including window 0.232

Self-rated poor, 1 if compared with those who are in the same age, self-rated 0.249 health health is poor

Medium, 2 if compared with those who are in the same age, self-rated 0.401 health is medium

Good, 3 if compared with those who are in the same age, self-rated 0.350 health is good

Income group Group1, if income in the bottom tertiles 0.328

Group2, if income in the middle tertiles 0.236

Group3, if income in the top tertiles 0.436

Migration-industry characteristics

Migrant 1 Another province 0.121 location 0 Another suburban area in Tianjin 0.879

Migrant 1 Accompanied if living with at least one family 0.741 accompanied

Page 8/20 Variable Properties and Variable defnitions Mean(± sd)

0 living alone without family member 0.259

Industry 1 Manufacturing, if working in the manufacturing industry 0.328

2 Retail, if working in the retail industry 0.293

3 Services, if working in the industry of services 0.379 Statistical analysis

We estimated the frequency of migrant workers’ intention to obtain the HB vaccination. Based on protection motivation theory, the PMT factors (severity factor, vulnerability factor, response efcacy factor, self-efcacy factor and response cost factor) were produced by principal component factor analysis. As set out in Models 1–3 below, socio-demographic characteristics variables, migration-industry variables and PMT factors were added into the binary logistic stepwise regression model, where the dependent variable was the intention to HB vaccinate.

1 1 1 1 Model 1: f (P)=α + β 1Xsociodemographic characteristics + ε

2 2 2 2 2 Model 2: f (P)=α + β 1Xsociodemographic characteristics + β 2XMigrant characteristics + ε

3 3 3 3 3 Model 3: f (P)=α + β 1Xsociodemographic characteristics + β 2XMigrant characteristics + β 3XPMT constructs factors + ε3

All statistical analysis was performed using STATA 15.1 with two-tailed tests at p = 0.05, 0.01 and 0.001 level.

Results

The characteristics of the 406 respondents are showed in Table 2, with 273 (67.2%) choosing to take the HB vaccine in the future, while 133 respondents (32.8%) chose not to vaccinate. Based on protection motivation theory and previous studies, we designed items for each PMT construct. Factor analysis and Cronbach’s alpha were employed to test the reliability and validity of the measurement tool and make sure that each item explain the relevant PMT construct fully. As PMT assumes a close relationship between some of the constructs, an oblique rotation specially designed to maximize the correlation among factors was selected to extract the factors [33].

Two factors (“The number of HBV patient and carrier is larger than before” and “The price of HB vaccine is very expensive”) whose contribution rate was less than 0.45, were screened out in the factor analysis [34]. Using the minimum eigenvalue criterion of 1.0, factor analysis yielded fve conceptually distinct factors that explained 87.13% of the total variance in measuring PMT. Except response cost with a

Page 9/20 Cronbach’s alpha of above 0.6, all the factors had Cronbach’s alpha values above 0.70 [35]. Table 1 displays the items, the assigned scores and Cronbach’s alpha value.

The results of binary logistic regression models are presented in Table 3. Migrant socio-demographic variables (Model 1), migration-industry variables (Model 2) and PMT factors (Model 3) were added through stepwise regressions. Given the nested characteristics of the models, the likelihood ratio test showed that the PMT constructs factors improved the goodness of ftness of the model (LR chi2 (5) = 30.700 and p = 0.000).

Page 10/20 Table 3 Migrant workers’ protection motivation to HB vaccinate Variables Model 1 Model 2 Model 3

Migrant Sociodemographic characteristics

Gender

Female 0.844(0.199) 0.812(0.196) 0.808(0.207)

Age 0.960(0.012)** 0.955(0.013)** 0.968(0.014)*

Education level

Senior high school or equivalent 0.680(0.272) 0.605(0.274) 0..492(0.240)

>Senior high school 1.105(0.352) 1.149(0.391) 1.045(0.388)

Marital status

Married 2.075(0.728)* 2.545(0.970)* 2.221(0.904)*

Self-rated health

Good 1.783(0.572) 2.058(0.702) 2.520(0.921)*

Medium 0.972(0.284) 1.161(0.357) 1.287(0.430)

Income group

Middle Group 2 0.615(0.188) 0.586(0.185) 0.536(0.179)

High Group 3 1.188(0.334) 1.374(0.398) 1.347(0.427)

Migration-industry characteristics

Migrant area

Migrant from different 2.638(1.092)* 3.408(1.591)** Tianjin suburb

Migrant accompanied

Accompanied 1.391(0.389) 1.405(0.428)

Industry

Retail 0.622(0.208) 0.611(0.221)

Service 1.062(0.368) 1.182(0.437)

Odds rations and standard errors are shown;* p < 0.05, ** p < 0.01, *** p < 0.001;The Reference group are “male”, “

Page 11/20 Variables Model 1 Model 2 Model 3

PMT factors

Severity 1.493(0.212)**

Self-efcacy 1.738(0.249)***

Response efcacy 0.900(0.140)

Vulnerability 1.291(0.213)

Response cost 0.612(0.105)**

Pseudo R2 0.053 0.077 0.151

P 0.003 0.000 0.000

-2LL 437.074 426.077 391.736

Odds rations and standard errors are shown;* p < 0.05, ** p < 0.01, *** p < 0.001;The Reference group are “male”, “

The socio-demographic variables in Table 3 show that younger, married and good self-rated health status participants were statistically associated with the intention of taking the HB vaccine. Sex, education level and income group were not signifcantly associated with vaccination intentions. The migration-industry variables show that migrant location had a strong effect on migrant workers’ vaccination intention. Tianjin migrant workers were more likely to choose the HB vaccine in the future than non-Tianjin migrants, while migrant workers accompanied by a family member(s) and industry type had no infuence on migrant workers’ vaccination intention.

For the PMT variables in Table 3, the severity factor and self-efcacy factor was positively and signifcantly related to HB vaccination intention (OR = 1.493, OR = 1.738) and the response cost factor was negatively and signifcantly related to motivation to take the HB vaccine (OR = 0.612). Comparing the three models, the self-rated health variable was insignifcant in Model 1 and Model 2, but statistically signifcant in Model 3.

Discussion

Consistent with the non-migrant vaccination studies in Korea, Brazil and China [17 18 36 37], Table 3 reports that migrant workers’ vaccination intention declined with age and sex was not statistically signifcant. Compared with the unmarried group, married migrant workers were more likely to take the HB vaccine. For self-rated health, the good health group was more likely to take up the HB vaccine than the poor health group, which is also consistent with previous non-migrant HB vaccination behavior studies

Page 12/20 [17]. This suggests that HBV prevention and education policy should focus on the migrant workers who are in the older and unmarried, and poor self-rated health status, groups.

Taking the migration-industry variables, only migrant location was signifcantly associated with vaccination intention, with the Tianjin migrant group more willing to choose HB vaccination than non- Tianjin migrants. This reinforces the recommendation that HBV health education and HB vaccination management policy should concentrate on migrant workers from other provinces. There were no signifcant differences whether the migrant worker was accompanied by family members and between the three industry groups. We expected industry differences since migrant workers in the retail and service industry were required by the government to undergo a physical examination to make sure they were not an HBV carrier before starting work. This absence of industry differences might refect a high level of inadequate HBV and HB vaccine knowledge of migrant workers irrespective of industry sectors. If migrant workers were ill-informed about HBV, then health ofcials missed an opportunity to educate migrant workers in services and retail industries on the benefts of the HB vaccine during the physical examination process. One place to improve migrant worker HBV education is during the existing testing of workers. We also recommend an expansion of the testing regime to all workplaces.

Validating our PMT approach, Model 3 shows that only severity, self-efcacy and response cost were the signifcant cognition factors determining HB vaccination intention. A meta-analysis of the literature on PMT found that not all PMT variables are able to predict a given behavior or intention with the same strength, with the role and infuence of PMT variables varying across different vaccination domains and research populations [25 26]. One of the most researched areas, infuenza vaccination intention, found that response efcacy and self-efcacy were signifcant predictors [38 39]. One study showed that compared to threat appraisal concepts (severity, vulnerability), coping appraisal concepts (response efcacy, self-efcacy and response costs) usually have stronger relationships with the adaptive intention to vaccinate [25]. Our results are consistent with these other PMT studies.

While a partial PMT migrant worker model was estimated by Liu et al (2019) [20], our full PMT model is the frst to estimate vaccination cost data, socio-demographic and migration-industry characteristics for migrant worker HBV vaccination intention in China. The smaller the HB vaccine costs, the higher the probability migrant workers intended to vaccinate (response cost factor OR = 0.612). Response costs, self-efcacy and severity from threat appraisal concepts were signifcant for migrant workers, which is consistent with non-migrant worker HBV studies. The odds-ratio (OR) value of severity was 1.493, which indicates that the probability of intention to take the HB vaccine would rise 1.493 units as the severity factor increased one unit. This means that when migrant workers were more likely to realize the serious and unrecoverable consequence of HB, there was a higher probability of them vaccinating. Also, the willingness to receive the HB vaccine would increase 1.738 units when the self-efcacy factor increased one unit (self-efcacy factor OR = 1.738).

Our results differ from Liu et al’s [20] partial PMT model, where vulnerability and response-efcacy were found to be the signifcant PMT factors determining migrants’ HB vaccination intention. The different

Page 13/20 results can be explained by the different study places, different measurement tools and different model specifcation, with Liu et al PMT model missing variables. Our fndings that severity, self-efcacy and response cost were signifcant PMT factors suggests that migrant populations need improved knowledge about the side effects of the HB vaccine and require information on HB , which should form a key content in health education. Management policy for improving the HB vaccination rate should eliminate these barriers to facilitate migrant worker’s vaccination rates

By including migration-industry variables, our paper also expanded the migrant worker HBV literature. As a vulnerable group, the migrants’ origins should be considered when measuring PMT. Our study follows previous non-migrant worker PMT subpopulations research, for instance, adolescent’s drug use and smoking, women’s preferences for contralateral prophylactic mastectomy and selective estrogen reuptake modulators and travellers' self-protections, by dissecting the migrant worker into Tianjin and non-Tianjin migrants [40–44]. As several PMT meta-analysis [25 26] showed, the specifcity of the PMT measurement for special populations are crucial, especially when PMT will be applied to provide guidance at the operational level. Our study identifed the crucial differences in the migrant population and the need to target subgroups of migrant workers.

Our fndings have important implications for health promotion, education design and immunization management. The social-demographic characteristics and migration-industry characteristics identifed the target migrant worker population for health education and immunization management policy: those who are older, unmarried, have poor self-rated health status and from outside Tianjin. Our threat evaluation results suggest that the content of HB education messages should emphasize the severity of HB, including identifying HBV symptoms, the heavy economic burden of HBV, the worries and pain of family members, the barriers to acquiring and potential social discrimination. We found coping evaluation, self-efcacy and response cost were strong predictors of migrant workers’ vaccination intention, which informs both health education content design and immunization management policy planning. Considering migrant workers’ characteristics, better health outcomes will depend on improving migrants’ self-efcacy, reducing the HBV response cost and expanding the accessibility to health and vaccination services for the migrant workers. Based on the signifcant role of self-efcacy in Table 3, health authorities should tap into work organizations as a location for vaccinations where other workers being vaccinated encourages individuals to vaccinate. According to the infuence of response cost factor in Table 3, the side effects of the HB vaccine should be included in the health education content and health authorities should provide more information on where, when and how to get the HB vaccine. Our study highlights the importance in health policies identifying subgroups, Tianjin and non-Tianjin migrants, within migrant worker populations. Our results suggest that health managers should establish more vaccination sites, especially workplaces, and visit existing injection service sites [32]. Study limitations

Maladaptive response rewards were not included in our PMT model. In some previous vaccination studies, maladaptive response rewards were measured by saving money or time, avoiding the side effects

Page 14/20 of the vaccine and acquiring natural immunity to subsequent infection [39 45]. Since HB is incurable, acquiring natural immunity does not exist, and saving expenses and worries about the side effects have been included in response cost, so maladaptive response rewards may not be a serious omission in our PMT model. However, the abandonment of maladaptive response rewards warrants empirical study in future HBV research.

Second, our study did not assess vaccination behaviour directly. While it has been shown that vaccination behavior in empirical studies can be predicted by previous intention in a wide range of contexts [46 47], future studies should include vaccination behavior directly. Third, as a result of convenience sampling, our results and fndings need confrmation through studies of other migrant worker populations, regions and industries.

Conclusion

Based on migrant workers’ protection motivation on HB and HB vaccine, this is the frst attempt to integrate all PMT constructs into an intention to vaccinate model. The results showed that the severity factor, self-efcacy factor and response cost factor were the three statistically signifcant PMT intention to vaccinate factors. The socio-demographic variables showed that younger, married and good self-rated health status participants were statistically associated with the intention of taking the HB vaccine. Sex, education level and income group were not signifcantly associated with vaccination intentions. The migration-industry variables show that migrant location had a strong effect on migrant workers’ vaccination intention. We recommend that health policies identify migrant worker subgroups, Tianjin and non-Tianjin migrants; tap into work organizations as a location for vaccinations; and provide more information on where, when and how to get the HB vaccine.

Abbreviations

HB: Hepatitis B; HBV:Hepatitis B Virus; NNDRS:National Notifable Diseases Reporting System; PMT:Protection Motivation Theory

Declarations Ethics approval and consent to participate

The study protocol was approved by The Ethical Committee of Tianjin University of Traditional Chinese Medicine. The investigation was performed after the acquisition of written informed consents of all participants. Participants were informed that they could refuse to answer any question. The questionnaire did not ask about infection status, and no biological samples were collected.

Consent for publication

Page 15/20 Not Applicable.

Availability of data and material

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

The research was supported by the National Natural Science Foundation of China (grant number 71303171, 71702131). The frst grant provided funding for the investigation and the second one offered the fnding for the interpretation of data.

Authors' contributions

CL and JW conceived of the research question and designed the study. CL did the statistical analyses, interpreted the results and drafted the article. SN revised the article critically providing important intellectual content. JW did the fnal approval of the version to be submitted. All authors read and approved the fnal manuscript.

Acknowledgements

The authors also thank Xiaofang Wang, Ying Li, Wenjing Lu, Yang Qin, and Zongpu Yue for their invaluable effort and support in the survey that made this study possible.

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Figures

Figure 1

PMT for intention to take HBV vaccineof migrant workers

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