- Email: [email protected]
Factors Associated With Seasonal Influenza Vaccination in Chinese Nursing Home Older Adults
772
Letters to the Editor / JAMDA 14 (2013) 768e774
References 1. Evans W. Functional and metabolic consequences of sarcopenia. J Nutr 1997; 127:998Se1003S. 2. Janssen I, Heymasfield SB, Ross R. Low relative skeletal muscle mass (sarcopenia) in older persons is associated with functional impairment and physical disability. J Am Geriatr Soc 2002;50:889e896. 3. Morley JE, Kaiser FE, Sih R, et al. Testosterone and frailty. Clin Geriatr Med 1997;13:685e695. 4. Banks WA, Morley JE. Endocrine and metabolic changes in human aging. J Am Aging Assoc 2000;23:103e115. 5. Morley JE. Is the hormonal fountain of youth drying up? J Gerontol Med Sci 2004;59:588e593. 6. Fried LP, Walston J. Frailty and failure to thrive. In: Hazzard WR, Blass JP, Ettinger WH, et al, eds. Principles of Geriatric Medicine and Gerontology. 5th ed. New York: McGraw-Hill; 2003, p. 1487-502. 7. Roubenoff R, Parise H, Payette HA, et al. Cytokines, insulin-like growth factor 1, sarcopenia, and mortality in very old community-dwelling men and women: The Framingham Heart Study. Am J Med 2003;115:429e435. 8. Lee KS, Park CH. Frailty. In: Cho JK, Michel JP, editors. Textbook of Geriatric Medicine International. 1st ed. Seoul: Argos; 2010. p. 331e338. 9. Statistics Korea. Available at: http://kostat.go.kr/portal/english/index.action. Accessed February 20, 2013. 10. Jeon GS, Jang SN. Park S. Social support, social network, and frailty in Korean elderly. J Korean Geriatr Soc 2012;16:84e94. 11. Jung JY, Kim JS, Choi HJ, et al. Factors associated with ADL and IADL from the Third Korea National Health and Nutrition Examination Survey (KNHANES III). Korean J Fam Med 2005;2009(30):598e609. 12. OECD. Long-term care: Growing sector, multifaceted systems. In: OECD. Help Wanted? Providing and Paying for Long-term Care. Available at: http://www. oecd.org/els/health-systems/47884520.pdf. Accessed March 1, 2013. 13. Park IS, Kim SK. Korean elderly long-term care insurance system and long-term care hospital. J Korean Geriatr Soc 2008;12:68e73. 14. Cho HS. The role of geriatric long-term care hospitals in geriatric long-term care. J Korean Geriatr Soc 2009;13S:25e39. 15. Ga H, Won CW. Guidebook of Long-term Care Hospitals for Doctors and Nurses. 1st ed. Seoul: Koonja Company; 2011. 16. Choi WS. The number of beds in long-term care hospitals exceeded 100,000. Available at: http://www.mdtoday.co.kr/mdtoday/index.html?no¼144027& cate¼. Accessed February 20, 2013. 17. National Health Insurance Corporation. Searching of long-term care hospitals. Available at: http://www.longtermcare.or.kr/portal/site/nydev/MENUITEM_ ORGSEARCH/. Accessed March 6, 2013. 18. Won CW. Elderly long-term care in Korea. Journal of Clinical Gerontology & Geriatrics 2012;3:1e3. 19. Seo YJ. Plan for role of long-term care hospital and long-term care facility. Health Insur Policy 2009;8:140e153. 20. Kim YB. A study on evaluation and improvement of long-term care hospitals for changing long-term care hospital fee system. Korean J Health Serv Manage 2011;5:105e117. 21. Song HJ. Long-term care hospital systems in developed countries and the implications for Korea. J Korean Geriatr Soc 2012;16:114e120. 22. Song YJ. The South Korean health care system. JMAJ 2009;52:206e209. 23. Health Insurance Review & Assessment Service. Statistical report. Seoul: Health Insurance Review & Assessment Service; 2012. 24. Won CW, Kim JY, Jeong IM. Suggestions for improving doctor’s opinion for the national long-term care insurance. J Korean Geriatr Soc 2009;13: 181e194. 25. Ministry of Health and Welfare. The present condition of long-term care facilities. Available at: http://stat.mw.go.kr/stat/depart/depart_list.jsp?menu_ code¼MN01020501. Accessed February 20, 2013. 26. Health Insurance Review & Assessment Service. Executive teaching material of medical fee system for geriatric nursing hospitals. Seoul: Health Insurance Review & Assessment Service; 2007. 27. CMS.gov. Nursing home quality initiative. Available at: https://www.cms.gov/ NursingHomeQualityInits/25_NHQIMDS30.asp. Accessed February 20, 2013. 28. Health Insurance Review & Assessment Service. The result of 2010 long-term care hospital assessment. In: Health Insurance Review & Assessment Service. Presentation of Long-term Care Hospital Assessment for Hospitalization Fees. Seoul: Health Insurance Review & Assessment Service; 2011. p. 23e34. 29. Health Insurance Review & Assessment Service. Presentation Material for Long-term Care Hospital Assessment. Seoul: Health Insurance Review & Assessment Service; 2009. 30. Health Insurance Review & Assessment Service. Practical Educational Material for Long-term Care Hospital Staffs. Seoul: Health Insurance Review & Assessment Service; 2010. 31. Ryu JH. “Lack of objectivity” for the raise of standard criteria of long-term care hospitals’ evaluation system. Available at: http://m.docdocdoc.co.kr/newsview. php?newscd¼2011101000041. Accessed March 22, 2013. 32. Park DJ. Long-term care hospitals’ strong complaints saying “We are ignorant of range or standard of the tests.” Available at: http://www.dailymedi.com/ news/view.html?section¼1&category¼4&no¼731382. Accessed March 22, 2013.
33. Son DH. An appropriate way of evaluation for long-term care hospitals. J Korean Geriatr Soc 2010;14:14e20. 34. Ministry of Health & Welfare. Presentation of Long-term Care Hospital Accreditation System. Seoul: Ministry of Health & Welfare; 2012.
Hyuk Ga, MD, PhD Department of Medicine Institute of Geriatric Medicine Incheon Eun-Hye Hospital Incheon, Korea Functional Assessment Committee for the Elderly (FACE) The Korean Geriatrics Society Seoul, Korea Chang Won Won, MD, MPH, PhD Functional Assessment Committee for the Elderly (FACE) The Korean Geriatrics Society Seoul, Korea Department of Family Medicine Kyung Hee University Hospital Seoul, Korea http://dx.doi.org/10.1016/j.jamda.2013.06.007
Factors Associated With Seasonal Influenza Vaccination in Chinese Nursing Home Older Adults To the Editor: Nursing home older adults have high infection-related hospitalization and mortality.1 Influenza vaccination can decrease hospitalization and mortality.2e4 In Hong Kong, annual seasonal vaccination is given to those who have given informed consent. For those who are mentally incompetent, consents are given by their guardians. There have been different studies about factors associated with influenza vaccination, but those studies mainly focused on community-dwelling older adults.5e7 To our knowledge, there is no study examining factors associated with influenza vaccination in nursing home older adults. Hence, we performed a cross-sectional study using a questionnaire based on the Health Belief Model (HBM) in older adults living in Chinese nursing homes.8 The study was conducted in May 2013 in the Hong Kong West Cluster (HKWC) of the Hospital Authority. In HKWC, there are 70 nursing homes taking care of 6000 residents. Nine nursing homes with 705 residents were selected for this study. The questionnaire was given through individual face-to-face interviews by the principal investigator to residents who had mental capacity to provide consent and agreed to participate in the study. The questionnaire included whether the resident would like to receive the influenza vaccination in 2013 and his or her perception toward influenza and influenza vaccination (Table 1). Other questions included the resident’s source of advice in receiving influenza vaccination. For this question, the participant could choose more than one answer. During univariate analysis for factors associated with influenza
Letters to the Editor / JAMDA 14 (2013) 768e774
773
Table 1 Influenza Vaccination Among Different Outcome Measurements and Predictors of Influenza Vaccination Behaviors in 155 Participants Question and Choice
No. (%)
Vaccinated No.* (%)
Age group 60e70 19 (12.8) 14 (73.7) 71e80 56 (37.8) 40 (71.4) 81e90 61 (41.2) 29 (47.8) >90 12 (8.1) 11 (90.9) Gender Female 107 (69.0) 75 (72.3) Male 48 (31.0) 28 (58.3) Perceived self-health Very good/good 85 (54.8) 63 (74.1) Poor/very poor 10 (6.5) 8 (80.0) No opinion 60 (38.7) 32 (53.3) Whether worried about contracting influenza in the next 12 months Worried 40 (25.8) 27 (67.5) Not worried 27 (17.4) 15 (55.6) Don’t know 88 (56.8) 61 (69.3) Perceived efficacy of influenza vaccination Efficacious 97 (62.6) 77 (79.4) Nonefficacious 30 (19.4) 12 (40.0) Don’t know 28 (18.1) 14 (50.0) Perceived side effects Severe/moderate 26 (16.8) 9 (34.6) Mild/not severe 71 (45.8) 58 (81.7) Don’t know 58 (37.4) 36 (62.1) Perceived severity of influenza Severe/moderate 90 (58.1) 71 (78.9) Mild/not severe 38 (24.5) 16 (42.1) Don’t know 27 (17.4) 16 (59.3) Ever vaccinated against influenza No 50 (32.3) 13 (26.0) Yes 105 (67.7) 90 (85.7) Any episode of pneumonia in the past No 106 (68.4) 74 (69.8) Yes 49 (31.6) 29 (59.2) Education level No 78 (50.3) 52 (66.7) Any 77 (49.7) 51 (66.2) Source of vaccination advice nHCWs 104 (67.1) 86 (82.7) Mass media 113 (72.9) 65 (57.5) Health talk 13 (8.4) 9 (69.2) Relative 71 (45.8) 60 (84.5)
Odds Ratio (Univariate)
Odds Ratio (Multivariate)
1 0.89 (0.28e2.89) 0.35 (0.11e1.08) 5.77 (0.15e12.65)
NS
1 0.66 (0.27e1.61)
NS
1 1.40 (0.28e7.09) 0.40 (0.20e0.81)
NS
1 0.60 (0.22e1.65) 1.09 (0.49e2.43)
NS
1 0.17 (0.07e0.42) 0.26 (0.11e0.63)
1
1 8.43 (3.08e23.07) 3.09 (1.18e8.13)
NS
1 0.20 (0.09e0.44) 0.39 (0.16e0.98)
1
1 17.1 (7.4e39.4)
1 13.32 (4.94e35.90)x
1 0.63 (0.31e1.27)
NS
1 0.98 (0.50e1.91)
NS
2.41 1.32 1.15 3.87
2.81 (1.07e7.98)y NS NS 3.45 (1.23e9.70)y
(1.20e4.86) (0.63e2.75) (0.34e3.92) (1.85e8.09)
0.25 (0.08e0.78)y 0.64 (0.20e2.05)
0.22 (0.07e0.66)z 0.37 (0.11e1.28)
nHCWs, nursing home health care workers; NS, not significant. *No. (percentage) within the choice. y P < .05. z P < .01. x P < .001.
vaccination, one of the answers in each question was used as the reference group. Factors univariately associated with influenza vaccination were used as input for multiple stepwise logistic regression to derive the multivariate odds ratio. This study was approved by the ethics committee of the HKWC, Hospital Authority. Among 705 residents, 23 were hospitalized, 490 did not have the capacity to give consent, and 37 refused to participate. Finally, 155 residents (age 79.0 9.7, 69% female) agreed to participate. Of the participants, 67.7% planned to receive an influenza vaccination in the coming year. Response to questions and factors associated with influenza vaccination are shown in Table 1. Multivariate analysis showed that residents were less likely than others to receive influenza vaccination if they (1) perceived influenza vaccination as “nonefficacious” and (2) perceived influenza infection as “mild/not severe.” On the other hand, residents were more likely to receive influenza vaccination if they (1) had received influenza vaccination in the past, or (2) a relative or nursing home health care worker (nHCW) had advised them to receive influenza vaccination.
In this study, although 72.9% of the participants had received advice in receiving influenza vaccination from mass media, 40% of the participants either thought influenza vaccination was nonefficacious or had no knowledge of the efficacy; 40% of the participants thought influenza infection was mild and not severe. Moreover, advice from mass media was not a predictor of influenza vaccination. Although mass media is the main channel to deliver information regarding influenza vaccination, those results suggested information delivered through this channel was inadequate and our results concurred with many previous studies.9 More emphasis should be put on the severity of influenza infection, and the efficacy and adverse effects of influenza vaccination. Moreover, the importance of health advice from relatives to older adults in receiving influenza vaccination should be emphasized, as it is an independent predictor of influenza vaccination. Another important finding was that advice from nHCWs was an independent predictor of influenza vaccination, as nHCWs are in day-to-day contact with residents. Health advice from nHCWs would be important and influential to the residents if they maintain a close rapport. More information regarding influenza vaccination,
774
Letters to the Editor / JAMDA 14 (2013) 768e774
especially efficacy and adverse effects, should be delivered to nHCWs. Prevaccination talks should be arranged in nursing homes or locations convenient for nHCWs. Information leaflets should be distributed to every nHCW. The nHCWs should also be encouraged to deliver advice on receiving influenza vaccination to residents. For nursing home older adults, compared with promotion through mass media, promotion through nHCWs is more likely to be effective. For residents who are socially isolated, this measure is even more important because nHCWs may be their main social contact. There were several limitations in this study. Only 27.2% of residents of the involved nursing home had the mental capacity to give consent. This is a common phenomenon faced by an intervention trial and questionnaire study for this population.10 Our results may not be generalizable to all nursing home older adults. However, among those with the mentally capacity for providing consent, the response rate was more than 80% and our result may be generalized to mentally competent residents. Further studies should be performed for the guardians of those mentally incompetent residents so as to provide a complete picture of factors associated with influenza vaccination. Also, this study was based on self-reported data and recall bias might exist. In conclusion, inadequate information regarding efficacy of influenza vaccination and severity of influenza infection were major barriers to receiving influenza vaccination in Chinese nursing home older adults. Health advice from relatives and nHCWs was an independent predictor. References 1. Chan TC, Hung IF, Cheng V, et al. Is nursing home residence an independent predictor of recurrent hospitalization in older adults [published online ahead of print June 15, 2013]? J Am Med Dir Assoc http://dx.doi.org/10.1016/j.jamda. 2013.05.008. 2. Chan TC, Hung IF, Shea YF, et al. Prevention of mortality and pneumonia among nursing home older adults by dual pneumococcal and seasonal influenza vaccination during a pandemic caused by novel pandemic influenza A (H1N1). J Am Med Dir Assoc 2012;13:698e703. 3. Chan TC, Hung IF, Luk JK, et al. Efficacy of trivalent seasonal influenza vaccination in reducing mortality and hospitalization in Chinese nursing home older adults [published online ahead of print May 21, 2013]. J AmMed Dir Assoc http://dx.doi.org/10.1016/j.jamda.2013.04.004.
4. Chan TC, Hung IF, Shea YF, et al. Efficacy of dual vaccination of pandemic H1N1 2009 influenza and seasonal influenza on institutionalized elderly: A one-year prospective cohort study. Vaccine 2011;29:7773e7778. 5. Kwong EWY, Lam IOY, Chan TMF. What factors affect influenza vaccine uptake among community-dwelling older Chinese people in Hong Kong general clinic? J Clin Nurs 2009;18:960e971. 6. Lau L, Lau Y, Lau YH. Prevalence and correlates of influenza vaccination among non-institutionalized elderly people: An exploratory cross-sectional survey. Int J Nurs Stud 2009;46:768e777. 7. Lau JTF, Kim JH, Yang X, et al. Cross-sectional and longitudinal factors predicting influenza vaccination in Hong Kong Chinese elderly aged 65 and above. J Infect 2008;56:460e468. 8. Rosenstock IM. The health belief model and preventive behavior. Health Education Monographs 1974;2:354e386. 9. Chor JSY, Pada SK, Stephenson I, et al. Seasonal influenza vaccination predicts pandemic H1N1 vaccination uptake among health care workers in three countries. Vaccine 2011;29:7364e7369. 10. Whelan PJ, Walwyn R, Gaughran F, et al. Impact of the demand for “proxy assent” on recruitment to a randomized controlled trial of vaccination testing in care homes. J Med Ethics 2013;39:36e40.
Tuen-Ching Chan, MBBS, FHKAM James Ka-Hay Luk, MBBS Felix Hon-Wai Chan, MBBch Department of Medicine and Geriatrics Fung Yiu King Hospital Hong Kong SAR, China Tuen-Ching Chan, MBBS, FHKAM Leung-Wing Chu, MD Division of Geriatrics Department of Medicine The University of Hong Kong Queen Mary Hospital Hong Kong SAR, China Ivan Fan-Ngai Hung, MD Division of Infectious Disease Department of Medicine The University of Hong Kong Queen Mary Hospital Hong Kong SAR, China http://dx.doi.org/10.1016/j.jamda.2013.06.008
Letters to the Editor / JAMDA 14 (2013) 768e774
References 1. Evans W. Functional and metabolic consequences of sarcopenia. J Nutr 1997; 127:998Se1003S. 2. Janssen I, Heymasfield SB, Ross R. Low relative skeletal muscle mass (sarcopenia) in older persons is associated with functional impairment and physical disability. J Am Geriatr Soc 2002;50:889e896. 3. Morley JE, Kaiser FE, Sih R, et al. Testosterone and frailty. Clin Geriatr Med 1997;13:685e695. 4. Banks WA, Morley JE. Endocrine and metabolic changes in human aging. J Am Aging Assoc 2000;23:103e115. 5. Morley JE. Is the hormonal fountain of youth drying up? J Gerontol Med Sci 2004;59:588e593. 6. Fried LP, Walston J. Frailty and failure to thrive. In: Hazzard WR, Blass JP, Ettinger WH, et al, eds. Principles of Geriatric Medicine and Gerontology. 5th ed. New York: McGraw-Hill; 2003, p. 1487-502. 7. Roubenoff R, Parise H, Payette HA, et al. Cytokines, insulin-like growth factor 1, sarcopenia, and mortality in very old community-dwelling men and women: The Framingham Heart Study. Am J Med 2003;115:429e435. 8. Lee KS, Park CH. Frailty. In: Cho JK, Michel JP, editors. Textbook of Geriatric Medicine International. 1st ed. Seoul: Argos; 2010. p. 331e338. 9. Statistics Korea. Available at: http://kostat.go.kr/portal/english/index.action. Accessed February 20, 2013. 10. Jeon GS, Jang SN. Park S. Social support, social network, and frailty in Korean elderly. J Korean Geriatr Soc 2012;16:84e94. 11. Jung JY, Kim JS, Choi HJ, et al. Factors associated with ADL and IADL from the Third Korea National Health and Nutrition Examination Survey (KNHANES III). Korean J Fam Med 2005;2009(30):598e609. 12. OECD. Long-term care: Growing sector, multifaceted systems. In: OECD. Help Wanted? Providing and Paying for Long-term Care. Available at: http://www. oecd.org/els/health-systems/47884520.pdf. Accessed March 1, 2013. 13. Park IS, Kim SK. Korean elderly long-term care insurance system and long-term care hospital. J Korean Geriatr Soc 2008;12:68e73. 14. Cho HS. The role of geriatric long-term care hospitals in geriatric long-term care. J Korean Geriatr Soc 2009;13S:25e39. 15. Ga H, Won CW. Guidebook of Long-term Care Hospitals for Doctors and Nurses. 1st ed. Seoul: Koonja Company; 2011. 16. Choi WS. The number of beds in long-term care hospitals exceeded 100,000. Available at: http://www.mdtoday.co.kr/mdtoday/index.html?no¼144027& cate¼. Accessed February 20, 2013. 17. National Health Insurance Corporation. Searching of long-term care hospitals. Available at: http://www.longtermcare.or.kr/portal/site/nydev/MENUITEM_ ORGSEARCH/. Accessed March 6, 2013. 18. Won CW. Elderly long-term care in Korea. Journal of Clinical Gerontology & Geriatrics 2012;3:1e3. 19. Seo YJ. Plan for role of long-term care hospital and long-term care facility. Health Insur Policy 2009;8:140e153. 20. Kim YB. A study on evaluation and improvement of long-term care hospitals for changing long-term care hospital fee system. Korean J Health Serv Manage 2011;5:105e117. 21. Song HJ. Long-term care hospital systems in developed countries and the implications for Korea. J Korean Geriatr Soc 2012;16:114e120. 22. Song YJ. The South Korean health care system. JMAJ 2009;52:206e209. 23. Health Insurance Review & Assessment Service. Statistical report. Seoul: Health Insurance Review & Assessment Service; 2012. 24. Won CW, Kim JY, Jeong IM. Suggestions for improving doctor’s opinion for the national long-term care insurance. J Korean Geriatr Soc 2009;13: 181e194. 25. Ministry of Health and Welfare. The present condition of long-term care facilities. Available at: http://stat.mw.go.kr/stat/depart/depart_list.jsp?menu_ code¼MN01020501. Accessed February 20, 2013. 26. Health Insurance Review & Assessment Service. Executive teaching material of medical fee system for geriatric nursing hospitals. Seoul: Health Insurance Review & Assessment Service; 2007. 27. CMS.gov. Nursing home quality initiative. Available at: https://www.cms.gov/ NursingHomeQualityInits/25_NHQIMDS30.asp. Accessed February 20, 2013. 28. Health Insurance Review & Assessment Service. The result of 2010 long-term care hospital assessment. In: Health Insurance Review & Assessment Service. Presentation of Long-term Care Hospital Assessment for Hospitalization Fees. Seoul: Health Insurance Review & Assessment Service; 2011. p. 23e34. 29. Health Insurance Review & Assessment Service. Presentation Material for Long-term Care Hospital Assessment. Seoul: Health Insurance Review & Assessment Service; 2009. 30. Health Insurance Review & Assessment Service. Practical Educational Material for Long-term Care Hospital Staffs. Seoul: Health Insurance Review & Assessment Service; 2010. 31. Ryu JH. “Lack of objectivity” for the raise of standard criteria of long-term care hospitals’ evaluation system. Available at: http://m.docdocdoc.co.kr/newsview. php?newscd¼2011101000041. Accessed March 22, 2013. 32. Park DJ. Long-term care hospitals’ strong complaints saying “We are ignorant of range or standard of the tests.” Available at: http://www.dailymedi.com/ news/view.html?section¼1&category¼4&no¼731382. Accessed March 22, 2013.
33. Son DH. An appropriate way of evaluation for long-term care hospitals. J Korean Geriatr Soc 2010;14:14e20. 34. Ministry of Health & Welfare. Presentation of Long-term Care Hospital Accreditation System. Seoul: Ministry of Health & Welfare; 2012.
Hyuk Ga, MD, PhD Department of Medicine Institute of Geriatric Medicine Incheon Eun-Hye Hospital Incheon, Korea Functional Assessment Committee for the Elderly (FACE) The Korean Geriatrics Society Seoul, Korea Chang Won Won, MD, MPH, PhD Functional Assessment Committee for the Elderly (FACE) The Korean Geriatrics Society Seoul, Korea Department of Family Medicine Kyung Hee University Hospital Seoul, Korea http://dx.doi.org/10.1016/j.jamda.2013.06.007
Factors Associated With Seasonal Influenza Vaccination in Chinese Nursing Home Older Adults To the Editor: Nursing home older adults have high infection-related hospitalization and mortality.1 Influenza vaccination can decrease hospitalization and mortality.2e4 In Hong Kong, annual seasonal vaccination is given to those who have given informed consent. For those who are mentally incompetent, consents are given by their guardians. There have been different studies about factors associated with influenza vaccination, but those studies mainly focused on community-dwelling older adults.5e7 To our knowledge, there is no study examining factors associated with influenza vaccination in nursing home older adults. Hence, we performed a cross-sectional study using a questionnaire based on the Health Belief Model (HBM) in older adults living in Chinese nursing homes.8 The study was conducted in May 2013 in the Hong Kong West Cluster (HKWC) of the Hospital Authority. In HKWC, there are 70 nursing homes taking care of 6000 residents. Nine nursing homes with 705 residents were selected for this study. The questionnaire was given through individual face-to-face interviews by the principal investigator to residents who had mental capacity to provide consent and agreed to participate in the study. The questionnaire included whether the resident would like to receive the influenza vaccination in 2013 and his or her perception toward influenza and influenza vaccination (Table 1). Other questions included the resident’s source of advice in receiving influenza vaccination. For this question, the participant could choose more than one answer. During univariate analysis for factors associated with influenza
Letters to the Editor / JAMDA 14 (2013) 768e774
773
Table 1 Influenza Vaccination Among Different Outcome Measurements and Predictors of Influenza Vaccination Behaviors in 155 Participants Question and Choice
No. (%)
Vaccinated No.* (%)
Age group 60e70 19 (12.8) 14 (73.7) 71e80 56 (37.8) 40 (71.4) 81e90 61 (41.2) 29 (47.8) >90 12 (8.1) 11 (90.9) Gender Female 107 (69.0) 75 (72.3) Male 48 (31.0) 28 (58.3) Perceived self-health Very good/good 85 (54.8) 63 (74.1) Poor/very poor 10 (6.5) 8 (80.0) No opinion 60 (38.7) 32 (53.3) Whether worried about contracting influenza in the next 12 months Worried 40 (25.8) 27 (67.5) Not worried 27 (17.4) 15 (55.6) Don’t know 88 (56.8) 61 (69.3) Perceived efficacy of influenza vaccination Efficacious 97 (62.6) 77 (79.4) Nonefficacious 30 (19.4) 12 (40.0) Don’t know 28 (18.1) 14 (50.0) Perceived side effects Severe/moderate 26 (16.8) 9 (34.6) Mild/not severe 71 (45.8) 58 (81.7) Don’t know 58 (37.4) 36 (62.1) Perceived severity of influenza Severe/moderate 90 (58.1) 71 (78.9) Mild/not severe 38 (24.5) 16 (42.1) Don’t know 27 (17.4) 16 (59.3) Ever vaccinated against influenza No 50 (32.3) 13 (26.0) Yes 105 (67.7) 90 (85.7) Any episode of pneumonia in the past No 106 (68.4) 74 (69.8) Yes 49 (31.6) 29 (59.2) Education level No 78 (50.3) 52 (66.7) Any 77 (49.7) 51 (66.2) Source of vaccination advice nHCWs 104 (67.1) 86 (82.7) Mass media 113 (72.9) 65 (57.5) Health talk 13 (8.4) 9 (69.2) Relative 71 (45.8) 60 (84.5)
Odds Ratio (Univariate)
Odds Ratio (Multivariate)
1 0.89 (0.28e2.89) 0.35 (0.11e1.08) 5.77 (0.15e12.65)
NS
1 0.66 (0.27e1.61)
NS
1 1.40 (0.28e7.09) 0.40 (0.20e0.81)
NS
1 0.60 (0.22e1.65) 1.09 (0.49e2.43)
NS
1 0.17 (0.07e0.42) 0.26 (0.11e0.63)
1
1 8.43 (3.08e23.07) 3.09 (1.18e8.13)
NS
1 0.20 (0.09e0.44) 0.39 (0.16e0.98)
1
1 17.1 (7.4e39.4)
1 13.32 (4.94e35.90)x
1 0.63 (0.31e1.27)
NS
1 0.98 (0.50e1.91)
NS
2.41 1.32 1.15 3.87
2.81 (1.07e7.98)y NS NS 3.45 (1.23e9.70)y
(1.20e4.86) (0.63e2.75) (0.34e3.92) (1.85e8.09)
0.25 (0.08e0.78)y 0.64 (0.20e2.05)
0.22 (0.07e0.66)z 0.37 (0.11e1.28)
nHCWs, nursing home health care workers; NS, not significant. *No. (percentage) within the choice. y P < .05. z P < .01. x P < .001.
vaccination, one of the answers in each question was used as the reference group. Factors univariately associated with influenza vaccination were used as input for multiple stepwise logistic regression to derive the multivariate odds ratio. This study was approved by the ethics committee of the HKWC, Hospital Authority. Among 705 residents, 23 were hospitalized, 490 did not have the capacity to give consent, and 37 refused to participate. Finally, 155 residents (age 79.0 9.7, 69% female) agreed to participate. Of the participants, 67.7% planned to receive an influenza vaccination in the coming year. Response to questions and factors associated with influenza vaccination are shown in Table 1. Multivariate analysis showed that residents were less likely than others to receive influenza vaccination if they (1) perceived influenza vaccination as “nonefficacious” and (2) perceived influenza infection as “mild/not severe.” On the other hand, residents were more likely to receive influenza vaccination if they (1) had received influenza vaccination in the past, or (2) a relative or nursing home health care worker (nHCW) had advised them to receive influenza vaccination.
In this study, although 72.9% of the participants had received advice in receiving influenza vaccination from mass media, 40% of the participants either thought influenza vaccination was nonefficacious or had no knowledge of the efficacy; 40% of the participants thought influenza infection was mild and not severe. Moreover, advice from mass media was not a predictor of influenza vaccination. Although mass media is the main channel to deliver information regarding influenza vaccination, those results suggested information delivered through this channel was inadequate and our results concurred with many previous studies.9 More emphasis should be put on the severity of influenza infection, and the efficacy and adverse effects of influenza vaccination. Moreover, the importance of health advice from relatives to older adults in receiving influenza vaccination should be emphasized, as it is an independent predictor of influenza vaccination. Another important finding was that advice from nHCWs was an independent predictor of influenza vaccination, as nHCWs are in day-to-day contact with residents. Health advice from nHCWs would be important and influential to the residents if they maintain a close rapport. More information regarding influenza vaccination,
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Letters to the Editor / JAMDA 14 (2013) 768e774
especially efficacy and adverse effects, should be delivered to nHCWs. Prevaccination talks should be arranged in nursing homes or locations convenient for nHCWs. Information leaflets should be distributed to every nHCW. The nHCWs should also be encouraged to deliver advice on receiving influenza vaccination to residents. For nursing home older adults, compared with promotion through mass media, promotion through nHCWs is more likely to be effective. For residents who are socially isolated, this measure is even more important because nHCWs may be their main social contact. There were several limitations in this study. Only 27.2% of residents of the involved nursing home had the mental capacity to give consent. This is a common phenomenon faced by an intervention trial and questionnaire study for this population.10 Our results may not be generalizable to all nursing home older adults. However, among those with the mentally capacity for providing consent, the response rate was more than 80% and our result may be generalized to mentally competent residents. Further studies should be performed for the guardians of those mentally incompetent residents so as to provide a complete picture of factors associated with influenza vaccination. Also, this study was based on self-reported data and recall bias might exist. In conclusion, inadequate information regarding efficacy of influenza vaccination and severity of influenza infection were major barriers to receiving influenza vaccination in Chinese nursing home older adults. Health advice from relatives and nHCWs was an independent predictor. References 1. Chan TC, Hung IF, Cheng V, et al. Is nursing home residence an independent predictor of recurrent hospitalization in older adults [published online ahead of print June 15, 2013]? J Am Med Dir Assoc http://dx.doi.org/10.1016/j.jamda. 2013.05.008. 2. Chan TC, Hung IF, Shea YF, et al. Prevention of mortality and pneumonia among nursing home older adults by dual pneumococcal and seasonal influenza vaccination during a pandemic caused by novel pandemic influenza A (H1N1). J Am Med Dir Assoc 2012;13:698e703. 3. Chan TC, Hung IF, Luk JK, et al. Efficacy of trivalent seasonal influenza vaccination in reducing mortality and hospitalization in Chinese nursing home older adults [published online ahead of print May 21, 2013]. J AmMed Dir Assoc http://dx.doi.org/10.1016/j.jamda.2013.04.004.
4. Chan TC, Hung IF, Shea YF, et al. Efficacy of dual vaccination of pandemic H1N1 2009 influenza and seasonal influenza on institutionalized elderly: A one-year prospective cohort study. Vaccine 2011;29:7773e7778. 5. Kwong EWY, Lam IOY, Chan TMF. What factors affect influenza vaccine uptake among community-dwelling older Chinese people in Hong Kong general clinic? J Clin Nurs 2009;18:960e971. 6. Lau L, Lau Y, Lau YH. Prevalence and correlates of influenza vaccination among non-institutionalized elderly people: An exploratory cross-sectional survey. Int J Nurs Stud 2009;46:768e777. 7. Lau JTF, Kim JH, Yang X, et al. Cross-sectional and longitudinal factors predicting influenza vaccination in Hong Kong Chinese elderly aged 65 and above. J Infect 2008;56:460e468. 8. Rosenstock IM. The health belief model and preventive behavior. Health Education Monographs 1974;2:354e386. 9. Chor JSY, Pada SK, Stephenson I, et al. Seasonal influenza vaccination predicts pandemic H1N1 vaccination uptake among health care workers in three countries. Vaccine 2011;29:7364e7369. 10. Whelan PJ, Walwyn R, Gaughran F, et al. Impact of the demand for “proxy assent” on recruitment to a randomized controlled trial of vaccination testing in care homes. J Med Ethics 2013;39:36e40.
Tuen-Ching Chan, MBBS, FHKAM James Ka-Hay Luk, MBBS Felix Hon-Wai Chan, MBBch Department of Medicine and Geriatrics Fung Yiu King Hospital Hong Kong SAR, China Tuen-Ching Chan, MBBS, FHKAM Leung-Wing Chu, MD Division of Geriatrics Department of Medicine The University of Hong Kong Queen Mary Hospital Hong Kong SAR, China Ivan Fan-Ngai Hung, MD Division of Infectious Disease Department of Medicine The University of Hong Kong Queen Mary Hospital Hong Kong SAR, China http://dx.doi.org/10.1016/j.jamda.2013.06.008