ISSU ES I N CLINICA L NUR SIN G
Health care worker beliefs about influenza vaccine and reasons for non-vaccination – a cross-sectional survey Helen Sarah Canning Medical Student, Department of Medicine, University of Liverpool, Liverpool, UK
Jennifer Phillips Medical Student, Department of Medicine, University of Liverpool, Liverpool, UK
Stephen Allsup MD Specialist Registrar, Department of Medicine, University of Liverpool, Liverpool, UK
Submitted for publication: 19 March 2004 Accepted for publication: 1 December 2004
Correspondence: Helen Sarah Canning 5 West Town Road Backwell Bristol BS48 3HA UK Telephone: þ44 1275 462968 E-mail:
[email protected]
Journal of Clinical Nursing 14, 922–925 Health care worker beliefs about influenza vaccine and reasons for non-vaccination – a cross-sectional survey Aims and objectives. To identify reasons for poor uptake of influenza vaccine in healthcare workers. Background. When influenza is circulating in the community, influenza vaccination of healthcare workers may reduce morbidity and sick leave and may also reduce mortality in older hospitalized patients. Despite this, vaccine uptake in healthcare workers remains low. Design. Cross-sectional survey. Methods. Self-completed questionnaires were distributed to 144 nurses and healthcare assistants in two Liverpool hospitals. Results. Vaccination uptake in this sample was 7.6%. The main reasons given for not being vaccinated were: did not think it was needed (29%), not aware of the vaccine (18%) and concerned about side-effects (11%). The main perceived benefits of vaccination were reducing sick leave (44%) and personal protection against influenza (28%). Conclusion. In this study, many healthcare workers demonstrated a lack of awareness and understanding of the vaccine, especially in relation to its benefits and side-effects. Relevance to clinical practice. Vaccinating healthcare workers against influenza can reduce staff sickness during times of winter pressure as well as reducing mortality in frail, older hospitalized patients. It is therefore important that hospitals maximize vaccine uptake by increasing awareness and promoting the benefits of influenza vaccine amongst healthcare workers as well as ensuring that all staff have the opportunity to receive the vaccine.
CANNING HS, PHILLIPS J & ALLSUP S (2005)
Key words: healthcare worker, influenza, influenza vaccination, nursing, uptake
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Introduction Vaccinating healthcare workers (HCW) against influenza has been shown to decrease mortality in frail, older hospitalized patients (Carman et al. 2000). This may be secondary to reduced virus transmission within the hospital. Other benefits of vaccinating HCW have also been demonstrated. Two double-blind randomized controlled trials (Saxen & Virtanen 1999, Wilde et al. 1999) have shown that influenza vaccination can reduce absenteeism caused by respiratory infections. One study found a reduction of 28% in the number of days of sick leave taken (Saxen & Virtanen 1999). Since 2000, as part of health service planning, the UK government has recommended that employers offer influenza vaccine to NHS staff (Department of Health 2000). Interventions designed to increase uptake have had varying success. A promotional programme using a public health nurse to raise awareness (Dey et al. 2001) did not significantly improve vaccine uptake, but an increase in uptake was reported following a vaccination fair, where senior members of staff were vaccinated in the presence of other staff who were then offered the vaccine (Thomas et al. 1993). A promotional programme using leaflets, memos, notices and presentations also managed to increase uptake (Smedley et al. 2002). Previous studies have examined the attitudes of HCW to influenza vaccine (Ballada et al. 1994, Habib et al. 2000, Smedley et al. 2002, Stephenson et al. 2002). Several reasons were found for non-vaccination. The belief that the vaccine is not effective and that influenza is not a serious disease was common, particularly amongst nurses. Many were also concerned about vaccine side-effects. Very few participants recognized that influenza vaccination could reduce transmission to patients. In the UK, despite the importance of influenza vaccination for both patients and staff, uptake of the vaccine amongst HCW remains low (Dey et al. 2001). The main aim of this study was to investigate why influenza vaccine uptake in HCW remains low in the UK.
Methods The survey was carried out in two Liverpool hospitals belonging to the same Trust during the period from January to March 2003. Anonymous, self-completed, numbered questionnaires were handed out to nurses and healthcare assistants. All staff who were on the ward at the time of the morning or afternoon handover were invited to participate. As well as background demographic data (age, gender, marital status and number of children at home), participants were also asked on the questionnaire whether or not the vaccine had been administered in the previous year (October–
Health care worker beliefs about influenza vaccine
December 2002), reasons for not being vaccinated and the perceived benefits of vaccination. A questionnaire asking participants to document side-effects following vaccination was handed out for those who had been vaccinated during the period specified. Data were analysed using Microsoft Access and SPSS (SPSS Inc., Chicago, IL, USA). Informed consent was obtained from all participants prior to entry into the study. The local research and ethics committee approved the study protocol.
Results Of the 233 HCW approached, 144 (61.8%) consented for the study, the main reason given for non-participation was lack of time during the busy handover period. Female participants comprised 76.2%, the mean age of the participants was 36 years (SD 10.3) and the median number of years as an HCW was 7.5. Of the 141 workers who specified their shift pattern, 52 worked during days only, 10 during nights only and 79 worked both days and nights. Forty-six of the respondents worked on a medical ward, 41 on a surgical ward, 38 on a geriatric ward and two were locum staff working in a number of different directorates (17 did not specify a directorate). Of the 144 participants, 11 (7.6%) indicated on the questionnaire that they had been vaccinated in the previous year. Data obtained from the occupational health department indicated that the total uptake for the two hospitals between October and December 2002 was 10.5% (551/5250). However, this total uptake included doctors, professions allied to medicine, administration and clerical staff as well as hospital porters and was not categorized by occupation. We compared vaccination status between gender, age, those living with a partner and those living alone, those with and without children at home, healthcare assistants and qualified nurses, those working days only and those who worked night shifts and those working on general wards and those working on geriatric wards. There was no significant difference in vaccination status between any of these groups (P > 0.05, chi-squared test). Of the 11 people who indicated that they had been vaccinated in the previous year, four (36%) stated that they had developed side-effects following vaccination. One participant complained of soreness around the injection site and aching limbs and another complained of a runny nose only. Two participants experienced multiple systemic side-effects, but only one person took any time off work because of sideeffects (a total period of seven days). We asked about sick leave taken during the three months prior to completion of the questionnaire (October–December 2002); 61.1% (88/144) of participants had taken sick leave in
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Discussion
Table 1 Reasons given for non-vaccination
Main reason for non-vaccination
No. of participants giving this reason (%)
Did not think it was needed Not aware of vaccine Just ‘did not want it’ (no reason given) Concerned about side-effects No time Never considered it Not available at convenient times Did not think it was beneficial Natural resistance preferred Absent from work when vaccine available Do not like injections Never had it in the past Forgot to get it Others
37 23 18 14 7 4 4 3 3 3 3 3 2 4
(28.9) (18.0) (14.1) (10.9) (5.5) (3.1) (3.1) (2.3) (2.3) (2.3) (2.3) (2.3) (1.6) (3.1)
this period (this included the one participant who took sick leave because of perceived side-effects following vaccination). Of these 88 participants, 45 (51.1%) had taken sick leave because of influenza-like illness. The participants were asked to state their main reason for not being vaccinated and 128 people responded (Table 1). About 49.6% (66/133) of people who were not vaccinated said they might be influenced to have the vaccine in the future. Of these 66 people, 40 gave a reason why they might consider vaccination in the future, with 10 (25%) stating that suffering from influenza would be a positive influence. Other positive influences were: if the vaccine was given on the wards or had increased availability (17.5%) and had no side-effects (5%). Of the 11 people who stated that they had been vaccinated in the previous year, five were vaccinated by their general practitioner and five by occupational health (one person did not give a response). The main reason given for vaccination was chronic illness. Four (36.4%) said that they had the vaccine every year. We asked all participants to identify what they thought were the benefits of vaccinating HCW. A total of 105 people responded to this question with one or more answers (Table 2). Table 2 Benefits of vaccination identified by participants No. of participants giving this response (%) Decreased sick leave of healthcare workers Personal protection against flu No benefits to vaccinating healthcare workers Preventing the spread of the virus Protecting patients from flu
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46 (43.8) 29 (27.6) 19 (18.1) 16 (15.2) 11 (10.5)
In this study, the main reason for poor vaccine uptake was a basic lack of knowledge and understanding of the vaccine, especially regarding benefits and side-effects. Many of the responses appeared to demonstrate general apathy towards vaccination. Almost half of the respondents were either not aware of the vaccine or did not think they needed it and only 10% of respondents knew that the benefits of the vaccine included the protection of patients against the serious complications of influenza. As found by Stephenson et al. (2002) and Ballada et al. (1994) the majority of participants cited the main benefit as personal protection against flu and reduced sick leave. Vaccine uptake amongst some HCW in this study was also affected by the availability of the vaccine. Between October and December 2002, the Occupational Health Department responsible for the staff influenza immunization programme in this Trust was only available to administer the vaccine one day per week during working hours (08:30–16:30 hours). Certain groups of staff would have had particular difficulty accessing this service, especially those working night shifts and locum staff. In this study, 56% (79/141) of HCW worked a mixture of both day and night shifts. An encouraging finding from our study was that half of those who had not been vaccinated stated that they might be influenced to have the vaccine in the future. This shows that an intensive hospital promotional programme might be very effective in significantly increasing uptake rates. Carman et al. (2000) achieved an uptake of 50.9% by providing dedicated vaccine nurses sited in clinical areas. These rates would be unlikely to be achieved in any hospital without such a facility. This was one of the barriers mentioned by almost one-fifth of the staff questioned in this survey, who stated that they would be influenced to have the vaccine next year if it was offered on the wards or had increased availability. In this study influenza vaccination was not significantly associated with age, gender, having children at home, ward type or shift pattern, although the numbers in the vaccinated group was small, increasing the likelihood of a type 2 error. In other studies, old age is a consistent factor associated with increased acceptance of the vaccine, but association with other factors such as length of employment, previous vaccination and marital status have also been demonstrated (Doebbeling et al. 1997, Chapman & Coups 1999, Stephenson et al. 2002). More than half of the participants in this sample claimed to have taken sick leave because of influenza-like illness during the period of October–December 2002. We are unable to say
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what proportion of this illness was caused by influenza. However, if vaccine uptake had been more widespread cases of illness attributable to influenza could have been prevented. This illness prevention, if repeated in all hospitals nationwide, could have a significant impact on ward staffing issues during the busy winter months when the incidence rates of influenza are greatest. To increase vaccine uptake significantly, however, will need extensive and sustained efforts to overcome a chronic lack of knowledge and interest, as highlighted in this study. A much more accessible vaccination service should be created that caters for the needs of all staff working within the hospital trust and should be inclusive of different shift patterns. Nurse immunisers could be funded to visit and administer the vaccine on the wards. Prior to starting the vaccination programme, an educational road show could visit all wards at different times to create awareness and interest in influenza and influenza vaccination. This could also be an ideal opportunity to allay fears and correct misconceptions that have developed around influenza vaccine. If such recommendations are put in place and maintained over successive years then the benefits to patients, staff and the NHS as a whole could be immense.
Acknowledgements We are especially grateful to Donna Friend and Mark Anders for help with data collection and would like to acknowledge Professor Margot Gosney for her tremendous all round support.
Contributions Study design: SA, HC, JP; data analysis: SA, HC, JP; manuscript preparation: SA, HC, JP.
Health care worker beliefs about influenza vaccine Vacca F (1994) Attitudes and behaviour of health care personnel regarding influenza vaccination. European Journal of Epidemiology 10, 63–68. Carman W, Elder A, Wallace L, McAulay K, Walker A, Murray G & Stott D (2000) Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial. Lancet 355, 93–97. Chapman GB & Coups EJ (1999) Predictors of influenza vaccine acceptance among healthy adults. Preventive Medicine 29, 249– 262. Department of Health (2000) 2000/01: Capacity Planning for Health and Social Care. DOH, London. Dey P, Halder S, Collins S, Benons L & Woodman C (2001) Promoting uptake of influenza vaccination in health care workers: a randomised controlled trial. Journal of Public Health Medicine 23, 346–348. Doebbeling BN, Edmond MB, Davis CS, Woodin JR & Zeitler RR (1997) Influenza vaccination of health care workers: evaluation of factors that are important in acceptance. Preventive Medicine 26, 68–77. Habib S, Rishpon S & Rubin L (2000) Influenza vaccination among healthcare workers. Israel Medical Association Journal 2, 899– 901. Saxen H & Virtanen M (1999) Randomised, placebo controlled double blind study on the efficacy of influenza immunisation on absenteeism of health care workers. Paediatric Infectious Disease Journal 18, 779–783. Smedley J, Palmer C, Baird J & Barker M (2002) A survey of the delivery and uptake of influenza vaccine among health care workers. Occupational Medicine 52, 271–276. Stephenson I, Roper JP & Nicolson KG (2002) Healthcare workers and their attitudes to influenza vaccination. Communicable Disease and Public Health 5, 247–252. Thomas DR, Winsted B & Koontz C (1993) Improving neglected influenza vaccination among healthcare workers in long-term care. Journal of the American Geriatrics Society 41, 928–930. Wilde JA, McMillan JA, Serwint J, Butta J, O’Riordan MA & Steinhoff MC (1999) Effectiveness of influenza vaccine in health care professionals: a randomised trial. Journal of the American Medical Association 281, 908–913.
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