What does the literature say?
- As influenza continues to burden mankind with both human and financial costs, qualitative and quantitative studies have focused upon discerning which attitudes and beliefs affect both acceptance and rejection of the vaccine along with strategies to improve vaccination rates among HCP (Hood & Smith, 2009; Nowalk et al., 2008; Willis & Wortley, 2007; McEwen & Farren, 2005; Bryant et al., 2004; Goldstein, Kincade, Gamble & Bearman, 2004).
- An important consideration in preparing flu vaccination education plans and strategies is to understand the audience and subsequently target interventions specifically to address the identified issues. Willis and Wortley (2007) found that both vaccinated and unvaccinated nurses expressed concern regarding safety and that the myths of flu vaccination prevail (vaccine can cause illness, perceived low susceptibility to illness and low efficacy of vaccine). Both groups felt that more HCP would receive vaccine if emphasis was placed on the rationale of protecting the patient.
- Bryant et al. (2004) found that vaccination rates in various health care settings ranged from 12%-68% after participating in an educational campaign to increase HCP adherence rates.The goal was to increase HCP annual flu vaccination to 50% or over and seven hospitals and eleven specialty units did achieve the goal. Beliefs such as protection of the patient, prior history of vaccination, avoidance of illness and missing work were cited as reasons for acceptance; reasons for refusal included inconvenience, allergy, beliefs--severe vaccine side effects, vaccine causes illness, low susceptibility to illness and the fear of needles. Strategies that were successful included fact cards and mobile carts.
- McEwen and Farren (2005) utilized survey methodology and found that the majority of the respondents stated receipt of flu vaccine. The beliefs identified concur with previous studies; vaccine efficacy and high perceived susceptibility were reasons for acceptance and getting illness from the vaccine and low perceived susceptibility reasons for refusal. Employer sponsored on-site vaccination also increased adherence.
- Also using the survey method, Nowalk et al. (2008) found that positive beliefs and attitudes toward the vaccine were held by the vaccinated group without variation among ethnic groups. The convenience of on-site vaccination and the protection of others also guided the acceptance of vaccination with the fear of side effects and low priority of receiving vaccine, the most common reasons for refusal. Techniques identified as effective were on-site/no cost vaccination, increased education re: the symptoms of influenza, the serious nature of the disease and stressing self protection; on unit vaccinators to promote correct information and efficacy of the vaccine were also effective.
- Goldstein, Kincade, Gamble and Bearman (2004) substantiated previous studies’ findings regarding beliefs/attitudes, but also found a low rate (38%) of written vaccination policy among the institutions queried. Additionally, the authors noted that 49% of the respondents supported either state or facility mandated vaccination.
- Hood and Smith (2009) implemented an effective influenza campaign with the goal of increasing an already high adherence rate for a large health system. A multidisciplinary team including leadership incorporated the mission/values of the organization, the organizational culture and data from previous campaigns to design a new strategy. An evidence-based, patient centered, personalized, educational approach was employed along with increased access to vaccination. The new campaign also utilized technology in the form of email slide education, a required online educational module and the use of the hospital intranet for motivation. The results were robust; vaccination rates climbed from 66% to 84.7% over a two year period. For specialty areas, the rates were even higher from 85% for the emergency department to 100% for hematology and oncology. The use of evidence-based research, a multidisciplinary team approach, role modeling, leadership involvement and technology combined to achieve the outstanding results.
Myths, side effects and the efficacy/safety of influenza vaccine:
- Myths include vaccine can give one influenza, HCP have a low probability of acquiring influenza, fear of the side effects of the vaccine and that the flu vaccine is not efficacious.
- HCP are a target group for vaccination efforts because of the high percentage (50%) of subclinical presentation of influenza; one may have the illness and not know it. Also many HCP go to work with symptoms which compromises the health of their patients (CDC, 2009).
- TIV is made from inactivated virus; the virus is killed and therefore does not have the propensity to cause influenza. LAIV contains attenuated virus which is weakened; LAIV may have the ability to cause mild signs/symptoms e.g., nasal congestion, runny nose, fever or a sore throat, but does not confer influenza (CDC, 2009).
- Side effects of the TIV form of the vaccine include soreness at the injection site, fever, myalgia, injection site reactions and headache; most of these effects last only 1-2 days. Guillian-Barre syndrome (GBS) has been associated with the 1976 swine influenza vaccine; the increased amount of cases noted were one case per 100,000 vaccinated and no causal link between influenza vaccination and GBS has been established. Subsequent risk for vaccine associated GBS has been found to be one case per 1 million vaccinated. Severe reactions to influenza vaccination are considered rare; the CDC notes that studies have indicated that approximately one in 500,000 vaccinations could result in anaphylaxis and most of these are related to egg allergy and vaccine components.
- Efficacy of the vaccine has been cited as a compelling reason for declination. In adults under 65 when vaccines are strongly matched to circulating virus, the prevention rates have reached 70%-90%; in years where the match was less than ideal, prevention rates have reached 47%-77% against laboratory confirmed influenza. In children, the ranges are from 66%-91% efficacy with laboratory confirmed analysis (CDC, 2009).
Methods to increase vaccination rates among HCP include:
- Utilize vaccine champions, informal leaders and leaders to role model behavior associated with vaccine adherence; create enthusiasm (motivation) which increases the likelihood of accepting vaccine.
- Requiring influenza vaccination as mandatory annual training and promoting vaccination during employee orientation underscores the importance that the organization feels towards the subject as well as its acceptance as a part of the organizational culture.
- Design educational delivery to include succinct modules based on evidence to increase perceived benefits/efficacy of vaccine, to inform and dispel myths without creating cognitive overload.
- Educational designs incorporating a strong teaching/learning such as the Health Belief Model or Social Learning Theory increase effectiveness.
- Offer LAIV for those (age appropriate) who have a fear of needles.
- Incorporate the use of technology in instructional design; the use of online modules and the WikiEducator to deliver content allows access 24/7. The use of intranet is another effective delivery system. WikiEducator may be accessed via: http://wikieducator.org/Main_Page. To develop a program, first create an account (password and login). The help page http://wikieducator.org/Help:Contents offers a wealth of information re: this format. The template cheat sheet Pedagogical templates and the wikieducator cheat sheet: http://wikieducator.org/Main_Page will also help. The tutorials on Wikieducator Tutorials are easy to follow and offer hands on examples. The specific template ProjectNav is an excellent template for organizing your design.
- Offer on-site/no cost vaccination on every shift; on unit vaccinators available throughout the shift also increases access.
- Develop written mandatory vaccination policies and include signed declination to gather data regarding refusal; use the data to gear new teaching/ learning efforts toward the identified rationales.
- Focus on Nursing’s role in the prevention of influenza and the protection of patients.