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Achieving optimal influenza vaccination rates: a survey-based study of healthcare workers in an urban hospital
Journal of Hospital Infection (2008) 70, 76e79
Available online at www.sciencedirect.com
www.elsevierhealth.com/journals/jhin
Achieving optimal influenza vaccination rates: a survey-based study of healthcare workers in an urban hospital M. Mehta*, C.A. Pastor, B. Shah BronxeLebanon Hospital Center, Bronx, New York, USA Received 4 September 2007; accepted 18 April 2008 Available online 3 July 2008
KEYWORDS Vaccination; Influenza; Healthcare workers; Staff attitudes
Summary In the USA, more than 36 000 deaths and 114 000 hospitalisations result from the influenza virus annually. Healthcare workers have been identified as a key source of influenza outbreaks. Despite Centers for Disease Control and Prevention recommendations to vaccinate all healthcare workers, the rate remains low. A survey-based investigation of influenza vaccination rates and related factors was carried out in an urban community teaching medical centre. A total of 570 surveys revealed a 56.5% influenza vaccination rate among participants. Participants who received the vaccine had a significantly higher mean influenza knowledge score compared to those who did not receive the vaccine (P ¼ 0.003). Also, a relationship was identified between those who received the vaccine and the perception that the purpose of the vaccine is to prevent patients from being exposed to influenza (P ¼ 0.001). Lastly, hospital departments in which managers actively encouraged and facilitated vaccination had higher rates in general. ª 2008 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction Influenza has a substantial mortality, morbidity, and economic cost. In the USA, the latest figures show an annual average of more than 36 000 * Corresponding author. Address: BronxeLebanon Hospital Center, 1650 Grand Concourse, Bronx, NY 10457, New York, USA. Tel.: þ1 718 518 5720; fax: þ1 718 716 8736. E-mail address: [email protected]
deaths and 114 000 hospitalisations resulting from influenza.1e3 The estimated cost from influenza-related hospitalisations and lost worker productivity range from US $400 000 to $1 billion. Pre-exposure vaccination remains the most effective option to combat influenza.1 Healthcare workers (HCWs) who are directly or indirectly involved with patient care are considered to be a key source of institutional and community outbreaks. Since 1981, the US Advisory Committee
0195-6701/$ - see front matter ª 2008 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2008.04.028
Optimising influenza vaccination rates on Immunization Practices (ACIP) has recommended influenza vaccination of all HCWs.4,5 Despite widespread efforts, the rates of influenza vaccination of HCWs remain low at 42% in 2006 [Centers for Disease Control and Prevention (CDC), 2006].6
77 representatives came to their department to vaccinate employees. The purpose of this tool was to understand if there was a relationship between these efforts and influenza vaccination rates.
Data entry and statistical analysis Study rationale and aims The idea for this study was conceived during a BronxeLebanon Family Medicine Department annual employee health-screening programme. A conspicuous number of HCWs refused the influenza vaccine for reasons ranging from ‘I do not believe in vaccines’ to even ‘the vaccine decreases spermatogenesis’. Thus, a survey was designed to identify vaccination rates among employees of the BronxeLebanon Hospital Centre, which groups refused the influenza vaccine, why they refused, and factors influencing their refusal. We also hoped to understand if there were relationships among vaccination rate, job position, and frequency of patient contact.
Methods Design and sample A cross-sectional design was employed. The sample for the study consisted of employees at BronxeLebanon Hospital Centre, an 858-bed, non-profit, community teaching medical centre located in the South Bronx. A convenience sampling method was used to collect data. The BronxeLebanon Hospital and Long Island University institutional review board committees approved the study procedures.
Data collection procedure and instruments First wave: The single-page questionnaire (Figure 1) contained eight questions, which fell into three categories: demographics, influenza vaccination perspectives, and knowledge of influenza. Prior to distribution, different healthcare departments ensured face validity of the survey items. To avoid bias, all employees were offered a survey with no or minimal explanation about the study. Each individual that filled out the confidential survey was entered into a raffle. The total survey response rate was >90%. Second wave: Managers were interviewed using a structured tool to assess their degree of encouragement, use of incentives, and distribution of literature to promote vaccinations. The managers were also queried if the employee health
The data from the surveys were entered into a Statistical Package for the Social Sciences database for analysis. Descriptive and univariate analyses were conducted and are presented.
Results In all, 570 surveys were collected. Approximately one-third was physicians and another one-fifth was nurses. The majority (78%) of the HCWs had multiple contacts with patients on a daily basis. However, there was no significant difference in vaccination rates when comparing the high versus low frequency of patient contact. Among those surveyed, the influenza vaccination rate for BronxeLebanon Hospital Center was 56.5%. The top two reasons for not receiving the influenza vaccine were ‘I feel like I do not need the vaccine’ (31.8%) and ‘I am afraid of getting sick from the vaccine’ (23%). A relatively small percentage (7.8%) claimed that the influenza vaccine was not offered. More than half of the respondents (58%) perceived that they are encouraged to be vaccinated because HCWs can be exposed to the flu by sick patients. Fewer respondents (16%) perceived that the vaccine is given because HCWs expose sick patients to the flu. Almost half of the respondents (48%) knew the correct estimated annual number of deaths in the USA from influenza. The majority (93% and 87%) of the respondents knew the correct answer to questions regarding CDC recommendations and the frequency of vaccination. Several interesting trends emerged when vaccination rates were examined by job position. The groups with above or close to par vaccination rate (as defined by The National Health Objective 2010 goal of 60%) were ‘physicians’ (74.7%), ‘pharmacists’ (66.7%), ‘dietary’ (65.2%), and ‘housekeeper/maintenance’ (58.5%). The ‘physical and respiratory therapist/nutritionist’ group had the lowest vaccination rate (16%). Interestingly, these rates do not correlate with the number of years of medical-related education. There was a significant difference (P ¼ 0.001) between physician rate of vaccination and non-physician rate of vaccination, where physicians had a higher rate of vaccination. The ‘physical and respiratory therapy/nutritionist’ group vaccination rate
78 was significantly lower than those not in that group (P ¼ 0.001). There was no difference between nurses (54.6%) and non-nurses. There were three survey questions gauging knowledge of influenza. Participants who received the influenza vaccine had a significantly higher (P ¼ 0.003) mean knowledge score (2.35 correct of 3) compared to participants who did not receive the influenza vaccine (2.17 correct of 3). However, when we compared the relationship between respondents who got all three knowledge questions correct and if they were vaccinated, we found no relationship (P ¼ 0.072). This may be due to other factors besides knowledge playing a role in the decision to receive the influenza vaccine. HCWs who received the influenza vaccine were three times more likely than those who did not receive the vaccine to indicate that influenza vaccines are encouraged because sick patients are exposed to influenza by HCWs (P ¼ 0.001). Other relationships between survey responses were also tested. The data indicated that there was no relationship between HCWs receiving the influenza vaccine and the perception that HCW vaccination is encouraged in order to minimise sick days and loss of productivity (P ¼ 0.09). The main study findings were that (i) a higher knowledge score of influenza, and (ii) the belief that the vaccine is to protect patients, were both correlated with increased HCW vaccination rates (r ¼ 0.26, P ¼ 0.004). Therefore, being educated on the epidemiology of influenza and CDC recommendations may increase vaccination rates. Furthermore, our findings suggest that HCWs may feel a personal sense of responsibility toward patients. Those who believe that they can protect their patients by accepting the influenza vaccine would more likely be immunised. Dietary and housekeeping departments achieved a 65% and 59% vaccination rate, respectively, despite the lack of any formal medical education. To understand which factors may have influenced vaccination in these departments, we queried the managers. We found an association between the departments that had the highest vaccination rates and a positive answer for ‘did employee health services vaccine (mobile cart) come to your department to administer the influenza vaccine?’. For physicians, pharmacists, nursing, and dietary workers, there was a mobile cart that came to the department to vaccinate on designated days. Additionally, some managers encouraged their staff to be vaccinated. This occurred in the dietary, physician, housekeeping, and laboratory departments. Dietary managers encouraged their employees on a face-to-face basis. A housekeeping
M. Mehta et al. manager led by example. Our physical and respiratory therapists had the lowest rates. They had no mobile cart, educational material, incentives, or in-depth encouragement.
Limitations Physicians comprised the largest percentage of responders (29.2%). Second, there were some groups of employees that were under-represented in the data collection, including night shift and outpatient clinic HCWs. Last, we cannot be certain that we captured all of the factors that played a role in individual department vaccination rates.
Discussion Vaccination and other disease preventive measures are well-documented to be key in the reduction of morbidity, mortality, and cost. Influenza vaccination of HCWs is a way in which acute care hospitals and long-term care facilities can make a large impact with a small investment of resources. As the findings of this study suggest, the decision to be vaccinated is a complex one influenced by both personal and systemic factors. An assumption that formal medical education leads to higher vaccination rates was not demonstrated in our or other studies.7 Nursing ranked lower than the dietary and housekeeping departments. Nurses in particular have been highlighted in the literature because of relatively low vaccination rates and unique barriers. This problem is compounded because unvaccinated nurses may be less comfortable promoting the vaccine to patients.8 Nurses also have ill-founded reservations about safety, lack of effectiveness, perception that they are not at risk because of a relatively stronger immune system, and belief that preventive measures are as effective as the vaccine.8 Mobile vaccination carts are favoured in the literature as a means to increase rates, which is supported in our study.6 Kimura showed that a combined educational campaign and a formalised ‘vaccine day’ programme increased the rate of vaccination to 53% compared to 27% in the control group.9 The Association of Professionals in Infection Control demonstrated improved rates when lead members of staff actively extolled the merits of vaccination. Our study expanded on this by highlighting the role of departmental managers in promoting vaccination. Other approaches, such as requiring staff to provide a written declination
Optimising influenza vaccination rates when refusing vaccination, have been shown to increase the rate of vaccination by two-fold.10 Conflict of interest statement None declared. Funding sources None.
Appendix A: Supplementary data A Supplementary data associated with this article can be found, in the online version, at doi:10.1016/ j.jhin.2008.04.028.
References 1. Bridges C, Kuehnert M, Hall C. Transmission of influenza: implications for control in health care settings. Clin Infect Dis 2003;37:1094e1101. 2. Thompson W, Shay D, Weintraub E, et al. Mortality associated with influenza and respiratory syncytial virus in the United States. J Am Med Soc 2003;289:179e186.
79 3. Bridges CB, Fukunda K, Uyeki T, Cox N, Singleton J. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2002;51(RR-3):1e31. 4. Lugo N. Will carrots or sticks raise influenza immunization rates of health care personnel? Am J Infect Control 2007; 35:1e6. 5. Pearson M, Bridges C, Harper S. Influenza vaccination of health-care personnel. Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2006;55(RR-02):1e16. 6. Centers for Disease Control and Prevention. Prevention and control of influenza. Recommendations of the advisory committee on immunization practices (ACIP), 2007 (early release). MMWR Recomm Rep 2007;56:1e54. 7. Polgreen P, Pottinger M, Polgreen L, Diekema D, Herwaldt L. Influenza vaccination rates, feedback, and the Hawthorne effect. Infect Control Hosp Epidemiol 2006;27:98e99. 8. Willis B, Wortley P. Nurses attitudes and beliefs about influenza and the influenza vaccine: a summary of focus groups in Alabama and Michigan. Am J Infect Control 2006; 35:20e24. 9. Kimura A, Nguyen C, Higa J, et al. The effectiveness of vaccine day and educational interventions on influenza vaccine coverage among health care workers at long-term care facilities. Am J Public Health 2007;97:684e690. 10. Nace D, Hoffman E, Resnick N, Handler S. Achieving and sustaining high rates of influenza immunization among long-term care staff. J Am Med Dir Assoc 2007;8:128e133.
Available online at www.sciencedirect.com
www.elsevierhealth.com/journals/jhin
Achieving optimal influenza vaccination rates: a survey-based study of healthcare workers in an urban hospital M. Mehta*, C.A. Pastor, B. Shah BronxeLebanon Hospital Center, Bronx, New York, USA Received 4 September 2007; accepted 18 April 2008 Available online 3 July 2008
KEYWORDS Vaccination; Influenza; Healthcare workers; Staff attitudes
Summary In the USA, more than 36 000 deaths and 114 000 hospitalisations result from the influenza virus annually. Healthcare workers have been identified as a key source of influenza outbreaks. Despite Centers for Disease Control and Prevention recommendations to vaccinate all healthcare workers, the rate remains low. A survey-based investigation of influenza vaccination rates and related factors was carried out in an urban community teaching medical centre. A total of 570 surveys revealed a 56.5% influenza vaccination rate among participants. Participants who received the vaccine had a significantly higher mean influenza knowledge score compared to those who did not receive the vaccine (P ¼ 0.003). Also, a relationship was identified between those who received the vaccine and the perception that the purpose of the vaccine is to prevent patients from being exposed to influenza (P ¼ 0.001). Lastly, hospital departments in which managers actively encouraged and facilitated vaccination had higher rates in general. ª 2008 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction Influenza has a substantial mortality, morbidity, and economic cost. In the USA, the latest figures show an annual average of more than 36 000 * Corresponding author. Address: BronxeLebanon Hospital Center, 1650 Grand Concourse, Bronx, NY 10457, New York, USA. Tel.: þ1 718 518 5720; fax: þ1 718 716 8736. E-mail address: [email protected]
deaths and 114 000 hospitalisations resulting from influenza.1e3 The estimated cost from influenza-related hospitalisations and lost worker productivity range from US $400 000 to $1 billion. Pre-exposure vaccination remains the most effective option to combat influenza.1 Healthcare workers (HCWs) who are directly or indirectly involved with patient care are considered to be a key source of institutional and community outbreaks. Since 1981, the US Advisory Committee
0195-6701/$ - see front matter ª 2008 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2008.04.028
Optimising influenza vaccination rates on Immunization Practices (ACIP) has recommended influenza vaccination of all HCWs.4,5 Despite widespread efforts, the rates of influenza vaccination of HCWs remain low at 42% in 2006 [Centers for Disease Control and Prevention (CDC), 2006].6
77 representatives came to their department to vaccinate employees. The purpose of this tool was to understand if there was a relationship between these efforts and influenza vaccination rates.
Data entry and statistical analysis Study rationale and aims The idea for this study was conceived during a BronxeLebanon Family Medicine Department annual employee health-screening programme. A conspicuous number of HCWs refused the influenza vaccine for reasons ranging from ‘I do not believe in vaccines’ to even ‘the vaccine decreases spermatogenesis’. Thus, a survey was designed to identify vaccination rates among employees of the BronxeLebanon Hospital Centre, which groups refused the influenza vaccine, why they refused, and factors influencing their refusal. We also hoped to understand if there were relationships among vaccination rate, job position, and frequency of patient contact.
Methods Design and sample A cross-sectional design was employed. The sample for the study consisted of employees at BronxeLebanon Hospital Centre, an 858-bed, non-profit, community teaching medical centre located in the South Bronx. A convenience sampling method was used to collect data. The BronxeLebanon Hospital and Long Island University institutional review board committees approved the study procedures.
Data collection procedure and instruments First wave: The single-page questionnaire (Figure 1) contained eight questions, which fell into three categories: demographics, influenza vaccination perspectives, and knowledge of influenza. Prior to distribution, different healthcare departments ensured face validity of the survey items. To avoid bias, all employees were offered a survey with no or minimal explanation about the study. Each individual that filled out the confidential survey was entered into a raffle. The total survey response rate was >90%. Second wave: Managers were interviewed using a structured tool to assess their degree of encouragement, use of incentives, and distribution of literature to promote vaccinations. The managers were also queried if the employee health
The data from the surveys were entered into a Statistical Package for the Social Sciences database for analysis. Descriptive and univariate analyses were conducted and are presented.
Results In all, 570 surveys were collected. Approximately one-third was physicians and another one-fifth was nurses. The majority (78%) of the HCWs had multiple contacts with patients on a daily basis. However, there was no significant difference in vaccination rates when comparing the high versus low frequency of patient contact. Among those surveyed, the influenza vaccination rate for BronxeLebanon Hospital Center was 56.5%. The top two reasons for not receiving the influenza vaccine were ‘I feel like I do not need the vaccine’ (31.8%) and ‘I am afraid of getting sick from the vaccine’ (23%). A relatively small percentage (7.8%) claimed that the influenza vaccine was not offered. More than half of the respondents (58%) perceived that they are encouraged to be vaccinated because HCWs can be exposed to the flu by sick patients. Fewer respondents (16%) perceived that the vaccine is given because HCWs expose sick patients to the flu. Almost half of the respondents (48%) knew the correct estimated annual number of deaths in the USA from influenza. The majority (93% and 87%) of the respondents knew the correct answer to questions regarding CDC recommendations and the frequency of vaccination. Several interesting trends emerged when vaccination rates were examined by job position. The groups with above or close to par vaccination rate (as defined by The National Health Objective 2010 goal of 60%) were ‘physicians’ (74.7%), ‘pharmacists’ (66.7%), ‘dietary’ (65.2%), and ‘housekeeper/maintenance’ (58.5%). The ‘physical and respiratory therapist/nutritionist’ group had the lowest vaccination rate (16%). Interestingly, these rates do not correlate with the number of years of medical-related education. There was a significant difference (P ¼ 0.001) between physician rate of vaccination and non-physician rate of vaccination, where physicians had a higher rate of vaccination. The ‘physical and respiratory therapy/nutritionist’ group vaccination rate
78 was significantly lower than those not in that group (P ¼ 0.001). There was no difference between nurses (54.6%) and non-nurses. There were three survey questions gauging knowledge of influenza. Participants who received the influenza vaccine had a significantly higher (P ¼ 0.003) mean knowledge score (2.35 correct of 3) compared to participants who did not receive the influenza vaccine (2.17 correct of 3). However, when we compared the relationship between respondents who got all three knowledge questions correct and if they were vaccinated, we found no relationship (P ¼ 0.072). This may be due to other factors besides knowledge playing a role in the decision to receive the influenza vaccine. HCWs who received the influenza vaccine were three times more likely than those who did not receive the vaccine to indicate that influenza vaccines are encouraged because sick patients are exposed to influenza by HCWs (P ¼ 0.001). Other relationships between survey responses were also tested. The data indicated that there was no relationship between HCWs receiving the influenza vaccine and the perception that HCW vaccination is encouraged in order to minimise sick days and loss of productivity (P ¼ 0.09). The main study findings were that (i) a higher knowledge score of influenza, and (ii) the belief that the vaccine is to protect patients, were both correlated with increased HCW vaccination rates (r ¼ 0.26, P ¼ 0.004). Therefore, being educated on the epidemiology of influenza and CDC recommendations may increase vaccination rates. Furthermore, our findings suggest that HCWs may feel a personal sense of responsibility toward patients. Those who believe that they can protect their patients by accepting the influenza vaccine would more likely be immunised. Dietary and housekeeping departments achieved a 65% and 59% vaccination rate, respectively, despite the lack of any formal medical education. To understand which factors may have influenced vaccination in these departments, we queried the managers. We found an association between the departments that had the highest vaccination rates and a positive answer for ‘did employee health services vaccine (mobile cart) come to your department to administer the influenza vaccine?’. For physicians, pharmacists, nursing, and dietary workers, there was a mobile cart that came to the department to vaccinate on designated days. Additionally, some managers encouraged their staff to be vaccinated. This occurred in the dietary, physician, housekeeping, and laboratory departments. Dietary managers encouraged their employees on a face-to-face basis. A housekeeping
M. Mehta et al. manager led by example. Our physical and respiratory therapists had the lowest rates. They had no mobile cart, educational material, incentives, or in-depth encouragement.
Limitations Physicians comprised the largest percentage of responders (29.2%). Second, there were some groups of employees that were under-represented in the data collection, including night shift and outpatient clinic HCWs. Last, we cannot be certain that we captured all of the factors that played a role in individual department vaccination rates.
Discussion Vaccination and other disease preventive measures are well-documented to be key in the reduction of morbidity, mortality, and cost. Influenza vaccination of HCWs is a way in which acute care hospitals and long-term care facilities can make a large impact with a small investment of resources. As the findings of this study suggest, the decision to be vaccinated is a complex one influenced by both personal and systemic factors. An assumption that formal medical education leads to higher vaccination rates was not demonstrated in our or other studies.7 Nursing ranked lower than the dietary and housekeeping departments. Nurses in particular have been highlighted in the literature because of relatively low vaccination rates and unique barriers. This problem is compounded because unvaccinated nurses may be less comfortable promoting the vaccine to patients.8 Nurses also have ill-founded reservations about safety, lack of effectiveness, perception that they are not at risk because of a relatively stronger immune system, and belief that preventive measures are as effective as the vaccine.8 Mobile vaccination carts are favoured in the literature as a means to increase rates, which is supported in our study.6 Kimura showed that a combined educational campaign and a formalised ‘vaccine day’ programme increased the rate of vaccination to 53% compared to 27% in the control group.9 The Association of Professionals in Infection Control demonstrated improved rates when lead members of staff actively extolled the merits of vaccination. Our study expanded on this by highlighting the role of departmental managers in promoting vaccination. Other approaches, such as requiring staff to provide a written declination
Optimising influenza vaccination rates when refusing vaccination, have been shown to increase the rate of vaccination by two-fold.10 Conflict of interest statement None declared. Funding sources None.
Appendix A: Supplementary data A Supplementary data associated with this article can be found, in the online version, at doi:10.1016/ j.jhin.2008.04.028.
References 1. Bridges C, Kuehnert M, Hall C. Transmission of influenza: implications for control in health care settings. Clin Infect Dis 2003;37:1094e1101. 2. Thompson W, Shay D, Weintraub E, et al. Mortality associated with influenza and respiratory syncytial virus in the United States. J Am Med Soc 2003;289:179e186.
79 3. Bridges CB, Fukunda K, Uyeki T, Cox N, Singleton J. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2002;51(RR-3):1e31. 4. Lugo N. Will carrots or sticks raise influenza immunization rates of health care personnel? Am J Infect Control 2007; 35:1e6. 5. Pearson M, Bridges C, Harper S. Influenza vaccination of health-care personnel. Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2006;55(RR-02):1e16. 6. Centers for Disease Control and Prevention. Prevention and control of influenza. Recommendations of the advisory committee on immunization practices (ACIP), 2007 (early release). MMWR Recomm Rep 2007;56:1e54. 7. Polgreen P, Pottinger M, Polgreen L, Diekema D, Herwaldt L. Influenza vaccination rates, feedback, and the Hawthorne effect. Infect Control Hosp Epidemiol 2006;27:98e99. 8. Willis B, Wortley P. Nurses attitudes and beliefs about influenza and the influenza vaccine: a summary of focus groups in Alabama and Michigan. Am J Infect Control 2006; 35:20e24. 9. Kimura A, Nguyen C, Higa J, et al. The effectiveness of vaccine day and educational interventions on influenza vaccine coverage among health care workers at long-term care facilities. Am J Public Health 2007;97:684e690. 10. Nace D, Hoffman E, Resnick N, Handler S. Achieving and sustaining high rates of influenza immunization among long-term care staff. J Am Med Dir Assoc 2007;8:128e133.