Effects of a multi-faceted program to increase influenza vaccine uptake among health care workers in nursing homes: A cluster randomised controlled trial

doi:10.1016/j.vaccine.2010.05.003

Vaccine

Volume 28, Issue 31, 12 July 2010, Pages 5086-5092

https://doi.org/10.1016/j.vaccine.2010.05.003 Get rights and content

Abstract

Despite the recommendation of the Dutch association of nursing home physicians (NVVA) to be immunized against influenza, vaccine uptake among HCWs in nursing homes remains unacceptably low. Therefore we conducted a cluster randomised controlled trial among 33 Dutch nursing homes to assess the effects of a systematically developed multi-faceted intervention program on influenza vaccine uptake among HCWs. The intervention program resulted in a significantly higher, though moderate, influenza vaccine uptake among HCWs in nursing homes. To take full advantage of this measure, either the program should be adjusted and implemented over a longer time period or mandatory influenza vaccination should be considered.

Introduction

Immunizing HCWs against influenza reduces the occurrence of influenza infections and associated productivity loss among HCWs [1], [2], [3]. Even more important, it enhances indirect protection of frail patients by reducing influenza virus transmission [4], [5], [6]. Following guidelines by the WHO, in 2004 the Dutch association of nursing home physicians (NVVA) recommended influenza vaccination of this specific target group [7]. In spite of this, vaccine uptake among HCWs in nursing homes remains unacceptably low [8], [9]. To be most effective, implementation programs to change behaviour should be built upon a coherent theoretical base and should target all relevant determinants of influenza vaccine uptake among HCWs [10], [11], [12]. To our knowledge, so far comprehensive studies on vaccination behaviour of this specific group are lacking and available studies assessing the impact of existing implementation programs were susceptible to bias because of their non-randomised design and therefore generalisability was limited [3].

Prior to the conduct of a cluster randomised implementation trial among HCWs in Dutch nursing homes, we assessed demographical, behavioural and organizational determinants of influenza vaccine uptake and were able to develop a 13-item multivariate prediction model with 95% accuracy among this target group [13]. The implementation program was largely based on these determinants and developed according to the intervention mapping method [14]. Our main objective was to assess the effectiveness of this systematically developed intervention program at cluster level. We also explored whether compliance to certain elements of the program influenced the outcome and estimated the program costs in terms of time and money [15].

Section snippets

Setting and study population

We performed a cluster randomised trial to assess the effects of a multi-faceted intervention program on the increase of influenza vaccine uptake among HCWs in Dutch nursing homes. In May 2006, all Dutch nursing homes (n = 335) were sent an invitation letter to participate in this study. Only nursing homes that did not intend to offer routine influenza vaccination to their HCWs were ineligible for the trial. By June 2006, 36 eligible nursing homes (11%) were included into the trial and were

Baseline characteristics of participating homes

After randomisation, but prior to the start of the program, two homes in the intervention group left the study due to general organizational difficulties (e.g. personnel shortage) that made execution of the implementation program impossible. In the control group one nursing home was excluded before analysing the data because HCWs had not been offered influenza vaccination during the study period which was the only eligibility criterion. In all, the implementation program was conducted in 16

Discussion

We showed that our multi-faceted intervention program resulted in an average 25% uptake of influenza vaccines among HCWs in the participating nursing homes and a significant 9% higher uptake compared with nursing homes that offered vaccines to HCWs as usual, with an average cost of only €1421 per intervention home. Vaccine uptake at nursing home level did show a large variation in effects between individual homes. Part of this variation in effect may be explained by the nursing home compliance

Acknowledgements

The study was funded by The Netherlands Organisation for Health Research and Development (ZonMw, grant nrs. 6300.0005 and 6330.0026). The authors are independent of the funders.

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Cited by (43)

A systematic review of barriers and enablers associated with uptake of influenza vaccine among care home staff
2023, Vaccine
Barriers and enablers to vaccination of care home (CH) staff should be identified in order to develop interventions to address them that increase uptake and protect residents. We aimed to synthesis the evidence describing the barriers and enablers that affect the influenza vaccination uptake of care home (CH) staff.
We searched PubMed, MEDLINE, EMBASE, CINAHL, PsycINFO, AMED, IBSS, SCOPUS to identify quantitative, qualitative or mixed-method studies. Data related to health or social care workers in CHs reported barriers or enablers were extracted and mapped to the Theoretical Domains Framework (TDF); the data within each domain were grouped and categorized into key factors affecting influenza vaccine uptake among CH staff.
We screened 4025 studies; 42 studies met our inclusion criteria. Thirty-four (81 %) were surveys. Five theoretical domains were frequently reported as mediators of influenza vaccine uptake: Beliefs about consequences (32 studies), Environmental context and resources (30 studies), Emotions (26 studies), Social influences (25 studies), Knowledge (22 studies). The low acceptance rate of the influenza vaccine among CH staff can be attributed to multiple factors, including insufficient understanding of the vaccine, its efficacy, or misconceptions about the vaccine (knowledge), perceiving the vaccine as ineffective and unsafe (beliefs about consequences), fear of influenza vaccine and its side effects (emotions), and experiencing limited accessibility to the vaccine (environmental context and resources).
Interventions aimed at increasing influenza vaccine uptake among CH staff should focus on addressing the barriers identified in this review. These interventions should include components such as enhancing knowledge by providing accurate information about vaccine benefits and safety, addressing negative beliefs by challenging misconceptions, managing concerns and fears through open communication, and improving accessibility to the vaccine through convenient on-site options. This review provides a foundation for the development of tailored Interventions to improve influenza vaccine uptake among CH staff.
Effectiveness of an intervention campaign on influenza vaccination of professionals in nursing homes: A cluster-randomized controlled trial
2019, Vaccine
Citation Excerpt :
In the absence of mandatory vaccination for professionals against seasonal influenza, incentives must be implemented. Randomized controlled trials in France [12,17] and in other countries [13,18–20] have shown that information campaigns could be effective, especially if they emphasize the individual benefit for the caregiver and his family. However, these campaigns should not involve organizational constraints, which would make it impossible to implement them on a larger scale, particularly in nursing homes not associated with health facilities, where the ratios of professionals are lower.
Seasonal influenza has a major individual and collective impact, especially among the elderly living in nursing homes. To prevent infection by influenza viruses, vaccination of residents and professionals is an essential measure. However, while the vaccination rates of residents are generally high (>85%), rates among professionals are generally approximately 20%. To evaluate the effectiveness of an intervention campaign on the improvement of the influenza vaccination rate of professionals, a regional intervention study was proposed for nursing homes during the 2014–15 season.
Cluster-randomized controlled trial (with a nursing home representing a cluster). In the intervention group, a campaign on influenza vaccination was offered to staff, combining different teaching aids in a multimodal approach. In the control group, no intervention was proposed. The primary endpoint was the rate of influenza vaccination among staff. Before and after the study, professionals were asked to complete short questionnaires on their perceptions of influenza vaccination. A multilevel analysis was carried out to compare the vaccination rates between the 2 groups and their evolution before/after the winter period.
A total of 32 nursing homes were randomized, and 6 were excluded. Initial vaccination rates were 27.6% in the intervention group and 24.2% in the control group (p = 0.16). After the study, these rates increased to 33.7% and 22.9%, respectively, which was a relative difference of +22.1% in the intervention group compared to −5.4% in the control group, p = 0.0025.
Despite professionals’ reluctance to be vaccinate, participation in a promotional campaign with a pragmatic approach has increased the rate of influenza vaccination. The approach will be offered to all nursing homes in the region after revision of the tools to enhance their ease of use and pedagogical messages focused on the direct benefits to professionals.
Attitudes, believes, determinants and organisational barriers behind the low seasonal influenza vaccination uptake in healthcare workers – A cross-sectional survey
2018, Vaccine
Citation Excerpt :
Demographic determinants such as gender, age and occupation can be used to define specific subgroups for intervention. Studies have shown that such well-prepared campaigns can be effective to increase vaccination uptake [38–40]. To achieve this in Flanders, Belgium, and in follow-up of the current study, an instruction manual, scientific brochure and promotional materials were developed for the implementation of performant and successful vaccination campaigns in all Flemish hospitals and nursing homes (available in Dutch on: http://www.laatjevaccineren.be/hou-griep-uit-je-team).
Seasonal influenza threatens hospitalised patients and residents of nursing homes annually. Due to age and chronic disease their protection following immunisation is diminished. Additional immunisation of direct contacts and in particular healthcare workers (HCWs) has proven added value. As vaccination coverage in HCWs remains low, we aimed to gain insight in the factors behind the demotivation for influenza vaccination.
Attitudes and believes towards influenza vaccination and socio-demographic and professional determinants were surveyed in 5141 Belgian HCWs from 13 hospitals and 14 nursing homes. Additionally, influenza campaign coordinators of the participating healthcare institutions were interviewed about the factors of success/failure in their campaigns.
The mean vaccination coverage registered by the participating healthcare institutions was 40.4% in the hospitals and 45.3% in the nursing homes. Overall, up to 90% of HCWs found it important not to infect their patients. However, only 20% of non-vaccinated HCWs considered influenza vaccination a duty to not harm their patients. Up to 40% of unvaccinated staff believed they could get influenza after vaccination and that vaccination weakens their immune system. Also, only about 20% of unvaccinated staff thought to have a high chance of getting influenza. Reasons for unvaccinated staff to get vaccinated in the future are self-protection and protection of family members. Factors that positively influenced vaccination coverage are encouragement by supervisors (OR, hospitals: 7.1, p < 0.001; nursing homes: 7.5, p < 0.001) and well-organized vaccination campaigns with on-site vaccination. Factors that negatively affected vaccination coverage are misconceptions about influenza and its vaccine (OR, range 0.1–0.7, p < 0.001 for most misconceptions) and underestimation of the risk of contracting influenza by patients or HCWs (OR of perceived susceptibility, range 2.1–5.1, p < 0.001 for most factors).
There is a need for guidance for the organization of seasonal influenza campaigns, in which education, communication and easy accessible vaccination are promoted.
“I wouldn't really believe statistics” – Challenges with influenza vaccine acceptance among healthcare workers in Singapore
2018, Vaccine
Influenza vaccine acceptance among healthcare workers (HCWs) is a worldwide problem, but relatively little research has focussed on Asia, including Singapore. Despite widespread access and recommendations from public health authorities, influenza vaccine uptake remains suboptimal among HCWs.
Our qualitative study used focus group discussions to identify and explain factors limiting influenza vaccine acceptance among HCWs in Singapore. A total of 73 doctors, nurses, allied health and ancillary staff across three public hospitals were included.
Challenges identified include a fear of contracting influenza from vaccination exacerbated by negative anecdotes regarding vaccine safety and efficacy, distrust of published efficacy data, uncertainty regarding relevance of existing data for Singapore, reluctance to introduce chemicals or overmedicate, pain from injection, low risk attributed to influenza and limited awareness of influenza transmission with a preference for alternatives in patient protection. Differences in attitudes were observed across vocational groups. Lack of overt promotion by hospital leadership in some institutions, perceived vaccine hesitancy among doctors, access, and work culture that implicitly encourages working through illness were further barriers.
Our findings highlight a combination of misperceptions about influenza vaccination and cognitive biases at the individual level, and challenges at the institutional level limiting uptake. Findings indicate an urgent need to provide targeted education and communication. Rather than providing more data, we recommend a widely-disseminated, locally-compiled synthesis addressing specific concerns of hesitant HCWs. Tailoring interventions to specific vocational groups should be considered. Institutional norms and culture may have a powerful influence in setting default behaviours: more effort is needed in improving influenza vaccine promotion and priority at some institutions, integrating vaccine-related communication with other infection control communication and addressing influenza vaccine hesitancy among doctors as a priority. Finally, further study of strategies to address cognitive biases affecting influenza vaccine acceptance in Singapore is desirable.
Knowledge and attitudes towards influenza vaccination of health care workers in emergency services
2017, Vaccine
Citation Excerpt :
Our results confirm completely the conclusions of the review of Zhang in which he indicates that greater knowledge and a positive attitude towards influenza and vaccination have a significantly positive association with vaccination coverage [11]. Other authors reported, in their review of literature on promotion of vaccination programs, the necessity of an initial phase of information through diverse media (individual emails, staff animated by a specialized nurse and repetition of these actions) [12,13]. Cultural and social factors also seem to us very important in the efficiency of any vaccination program.
Annual vaccination rates among French health care workers (HCWs) are in decline even in Emergency Services to which patients at highest risk of influenza complications are admitted, and in which HCWs have the greatest risk of exposure to influenza from patients. We aimed here to identify knowledge and attitudes towards influenza vaccination of HCWs in Emergency Services. We collected 344 self-administered questionnaires of 1060 HCWs. Only 18% of HCWs were vaccinated against influenza. Physicians were vaccinated more often (55%) than nurses (16%) or aid nurses (11%). The most important barriers to vaccination were reported as being a lack of time (33%), lack of safety of the vaccine (31%), fear of contracting influenza due to vaccination (29%), and lack of effectiveness (23%). Being vaccinated was significantly related to a higher knowledge score based on epidemiological influenza items (OR (95% CI)) (1.63 (1.08–2.46)) and vaccine features items (2.36 (1.36–4.10)).
The seasonal flu vaccination among caregivers in geriatric units: Up-to-date
2016, Revue d'Epidemiologie et de Sante Publique
La vaccination antigrippale des professionnels de santé semble représenter l’une des actions préventives des plus efficaces face à une pathologie à haut risque d’épidémie nosocomiale et potentiellement grave en milieu gériatrique. Ce travail avait pour objectif de faire une mise au point sur le statut vaccinal antigrippal chez le personnel soignant en gériatrie et les raisons expliquant leur réticence vis-à-vis de cette vaccination, afin d’émettre des propositions d’amélioration de la couverture vaccinale.
Une recherche bibliographique des articles publiés depuis 2000 dans le domaine de la gériatrie, des maladies infectieuses ou de la pneumologie a été réalisée, essentiellement sur PubMed. Les principaux mots-clés utilisés pour la recherche étaient « caregivers », « elderly », « flu », « influenza », « nosocomial » et « vaccination ». Tous les résumés en anglais ou en français, issus de cette première sélection, ont été lus par les auteurs afin d’écarter les articles hors sujet. Au final, 64 articles ont été cités dans la bibliographie de cette mise au point.
Malgré les recommandations officielles, la littérature révèle une couverture vaccinale de ce personnel insuffisante à l’échelle nationale et internationale. La couverture vaccinale apparaît plus faible chez le personnel féminin, plus jeune et non médical. Les déterminants pour la vaccination sont le désir de se protéger soi-même, de protéger sa famille et les patients/résidents, ainsi que le vécu grippal antérieur. Les facteurs d’opposition à la vaccination sont complexes, liés à la peur des effets secondaires, au recours à d’autres moyens préventifs, au sentiment d’inefficacité vaccinale, à la mauvaise connaissance de la maladie et du vaccin et aux problèmes organisationnels. Les campagnes de promotion vaccinale, destinées à responsabiliser le professionnel de santé, doivent être multidimensionnelles et fortement incitatives. Le message pédagogique doit être centré sur le bénéfice individuel et adapté selon les catégories socio-professionnelles. Les stratégies incitatives mobiles au sein des services sont déjà une déclinaison pragmatique de ce défi. Le médecin traitant est un pivot incontournable, ainsi que le médecin du travail en lien avec les services d’hygiène hospitalière.
La vaccination antigrippale doit s’inscrire dans l’éducation et la formation du personnel soignant.
Flu vaccinations for healthcare professionals seems to be one of the most effective preventive actions in the face of a disease that carries a high risk of a potentially serious nosocomial epidemic in a geriatric environment. The aim of this study was to take stock of the flu vaccination status among caregivers in the geriatric units and to understand the reasons for their reluctance to be vaccinated, in order to put forward proposals to improve vaccination coverage.
A literature search of articles published since 2000 in the area of geriatrics, infectious diseases or pneumology was mainly conducted on PubMed using the keywords “caregivers”, “elderly”, “flu”, “influenza”, “nosocomial” and “vaccination”. After reading all abstracts in English or French and ruling out irrelevant articles, only 64 relevant articles have been listed in bibliography section.
Despite official recommendations, the literature reveals insufficient vaccination coverage of healthcare personnel at both the national and international level. Vaccination coverage seems to be lower among younger female non-medical staff. The factors that determine the likelihood of vaccination are the wish to protect one's self, one's family and patients/residents, as well as the experience of earlier bouts of flu. Factors that oppose vaccination are complex and related to the fear of side effects, the use of other preventive measures, the feeling that vaccination is ineffective, poor understanding of the disease and the vaccine, forgetfulness and problems of organization. Campaigns to promote vaccination that target healthcare professionals must be multidimensional and very incentive. The pedagogical message must be centered on the benefits to the individual and adjusted to socio-professional categories. Mobile strategies in the different departments to encourage staff are a pragmatic solution to this challenge. The referring doctor has an essential role to play, as does the occupational doctor in association with the hospital hygiene services.
Flu vaccinations must be included in the education and training of caregivers.

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Effects of a multi-faceted program to increase influenza vaccine uptake among health care workers in nursing homes: A cluster randomised controlled trial

Abstract

Introduction

Section snippets

Setting and study population

Baseline characteristics of participating homes

Discussion

Acknowledgements

Vaccine

Lancet

Vaccine

J. Am. Med. Dir. Assoc.

Vaccine

Vaccine

Effectiveness of influenza vaccine in health care professionals: a randomized trial

JAMA

Randomized, placebo-controlled double blind study on the efficacy of influenza immunization on absenteeism of health care workers

Pediatr. Infect. Dis. J.

Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial

BMJ

The effects of influenza vaccination of health care workers in nursing homes: insights from a mathematical model

PLoS Med.

Practice guideline ‘Influenza prevention in nursing homes and care homes’, issued by the Dutch Society of Nursing Home Specialists

Ned. Tijdschr. Geneeskd.

Uptake of influenza vaccination in Dutch nursing home personnel following national recommendations

J. Am. Geriatr. Soc.

On the trail of quality and safety in health care

BMJ

Effectiveness and efficiency of guideline dissemination and implementation strategies

Health Technol. Assess.

Personal paper. Beliefs and evidence in changing clinical practice

BMJ

What drives change? Barriers to and incentives for achieving evidence-based practice

Med. J. Aust.