Influence of physician's recommendation on influenza immunization: perception and acceptance among a group of institutionalized elderly

Serodiagnosis

and Immunotherapy

in Infectious Disease (1990)4, 1677I7 1

Leading article Influence of physician’s recommendation on influenza immunization: perception and acceptance among a group of institutionalized elderly R. Ganguly’, T. B. Webster’, H. Chmel and B. V. Yangco’

\James A. Haley Veterans’ Hospital, 13000 Bruce B. Downs Blvd, Tampa, Florida and ‘Bay Pines, VA Medical Center, St. Petersburg. Florida

Elderly residents(201, mostly male 2 65 yearsold) from the VA nursinghomecare unit (NHCU) in Florida were surveyed by a questionnaire as to whether they had been voluntarily acceptinginfluenza vaccine in the past and what factors had affected their decision.Theseveteranshad an averagelength of stay at the NHCU of 12 months and 270% sufferedfrom chronic diseases with a past history of smoking. Physician recommendation concerningimmunization was found to be the most significantfactor for vaccinecompliance. Over half of the residentsimmunizedwithin the past year could recafl a physician personally giving a recommendation for vaccination. Among thosenot immunizedduring the year, 22% did not have yearly physician’srecommendationand cited reasonssuchas unawarenessof vaccineneed,20% dislikedor fearedthe sideeffectsand 14%lackedgeneralmotivation. Thesedata indicate that physicianintervention plays a strong role in the acceptance of influenza vaccination among hospitalized elderly veteransand appearsto be more effective than the usualstandingNHCU practiceof vaccine offered by the nursing staff. The data also suggest that educational intervention measures may bebeneficial,yet, not aseffective asphysician’sintervention.

Introduction

Abstract:

elderly, influenza prophylaxis, immunization compliance,vaccines. Keywords:

08884786/90/030167+ 05 $03.00/O

Influenza vaccineshavebeenrecommended for certain groups consideredat a high risk for contracting influenza.Theseincludeall persons with chronic diseases needingmedicalattention and/or individuals over 65 yearsof age’.It has beenreported that the elderly suffer from the highestdeath rates from complicationsduring pandemicsof influenza*.During interepidemic outbreaks of influenza, hospitalization rates have beenreported to be six-fold or higher for pneumonia and influenza among otherwise healthy elderly’. It has been suggestedthat since the elderly population is increasing, influenza will remain a health problem4.Despite the recommendationby the Advisory Committee on Immunization Practicesof the Public Health Servicefor influenzavaccination since1964,the overall vaccineacceptancerate amongthosein high risk groupshasremained low (< 30%)5.This rate is far from the national goal of at least60% immunizationcoverageby 19906.It is necessaryto elucidateand correct the obstaclesto voluntary influenza immunization by the elderly population which significantly reducescomplicationsfrom influenza, hospitalization and mortality from this infection. Therefore, this study was designedto determine the acceptanceand perception of influenza immunization among one high risk segmentof the population: the institutionalized veterans. who are offered as a routine, influenza vaccine by the nursing staff of the NHCU.

167

KJ 1990Academic PressLimited

168

Leading article Method

This investigation was conducted at the NHCU of the Bay Pines Veterans Administration (VA) Medical Center, St. Petersburg, Florida, after approval from the Institutional Review Board. Patients were screened, based on their ability to give good cognitive responses and medical eligibility for receiving influenza vaccination. NHCU residents unable to respond to verbal/ written questions and/or having contraindications for influenza vaccination were excluded from the study. Of the 240 NHCU residents, 201 (84%) were identified as eligible for the study based on these exclusion/inclusion criteria. After giving their informed consent, all 201 were admitted into the study. A questionnaire regarding medical history, demographics, and attitudes toward influenza immunization was developed. The questionnaire was then administered orally by a technician in the form of an interview in the patient’s room. The technician annotated the appropriate areas of the questionnaire according to the reply given by all 201 participants. As a routine procedure, NHCU residents are offered influenza vaccine each Fall by the nursing staff. Study subjects were not offered vaccination as part of this study and acceptance rate after the interview was not determined. All patients admitted to the study were interviewed and data were analyzed by z-test and chi-square analysis to determine significance and identify trends. In order to estimate the degree of recall bias, medical records were compared to the responses of all but 6 subjects (97%) being interviewed.

Results The study population consisted mainly of white males (96%) with a median age of 70.6, where 7 1% had smoked tobacco for an average of 10 years and 74% had been suffering from 2.2 chronic illnesses. The latter included predominantly high blood pressure and cancer followed by lung disease, diabetes and heart disease in decreasing order of incidence. Of the 201 NHCU residents interviewed, approximately one third had been immunized against influenza during the past year and were defined as the compliant group in this study (Table 1). Fifty four study subjects (26%) had been immunized at some time during the past 5 years. Subjects vaccinated l-5 years previously,

by far exceeded the number of subjects who were immunized > 5 years ago or who were not sure or had never accepted immunization (nearly 2: I ). Vaccination acceptance was correlated against physician’s recommendation and was found to have a significant effect on subjects’ compliance rate (Table 2). The highest immunization rate (27/28 subjects) occurred among patients who indicated that at least once a year a physician had given them a recommendation to be immunized. Twenty-six of 45 veterans received immunization in the past year who were instructed by physicians 1-5 years previously. It is interesting to note that only one of 28 subjects (3.7%) instructed yearly by a physician for vaccination was non-compliant in the past year, whereas 19 of 45 subjects (42%) instructed l-5 years previously by a physician were non-compliant during the past year. The figure for the “never instructed group” was 82% (75 of 91 subjects remained unimmunized, Table 2). No immunization occurred among those not recalling any physician’s advice (0% in the “not sure” group). The decline in immunization rate with decline in physician recommendation was thus observed in the following order amongst groups: yearly instructed, lL5 years previously instructed, never instructed and those that were not sure about instruction. Compliance was significantly higher in those with yearly physician recommendation compared to other groups (Table 2). Compliance in the “l-5 years instructed” group also exceeded significantly those of the “never instructed” and “not sure” groups. It appears that when the subjects were never instructed by a physician, vaccine acceptance occurred at a steady low rate (8-9%, Table 2). but these did not represent a static compliant population. Of all subjects studied, 102 veterans (50%) had yearly contact with a physician (data not shown). Twenty-eight (26%) of those remembered yearly physician’s advice for immunization; 27 of those were compliant in the past year (Table 2). No trend was apparent between having lung disease/smoking history with higher vaccine compliance amongst study subjects. However, 36% of the veterans with chronic disease(s) were vaccine compliant as opposed to 13.4% of those who reported not having any chronic illness (data not shown). Of the individuals who were not immunized last year, 62 subjects had more than one reason. another 62 had one reason and 9 gave no reason for not receiving the influenza vaccine.

169

Leading article Table 1. Influenza

vaccine acceptance among NHCU* Number

Last influenza immunization ---~ ~ Past year Between l-5 years More than 5 years ago Never Not sure Total * NHCU-Nursing

Home

Care Unit

Table 2. Physician recommendation Frequency of physician advice Yearly l-5 years Never Not sure Column

total

Number

residents Percent

69 54 37 2x 24

34 26 14 14 12

201

100

at the VA hospital.

and vaccine acceptance among NHCU

accepting influenza

vaccination

Past year

l-5 years

> 5 years

27-f 26; 16 0

0 12 17 18

1 I 18 I

‘I I

0 0 13 11

69

47*

21

28

24

* Seven subjects did not answer this question. t Compliance in the “yearly instructed” group significantly P Compliance in the “l-5 yrs instructed” group significantly sure” group, Pi 0.0 I

The most prevalent reason proved to be unawareness of vaccine recommendation (A, 22% of all reasons) followed by fear or dislike of side effects (D and E combined, 20%) and general lack of motivation (B, 15%) (Figure 1). Those who were previously receiving the vaccine yet failing to do so the current year were analyzed further in order to determine factors for noncompliance (82 subjects, Table 3). Lack of motivation (16% of total responses) followed by bad side effects in the past (14%) and unawareness of vaccine requirement (13%) were most prevalent reasons. Those never immunized cited fear of side reactions (62%) and those unsure of their immunization status unanimously cited lack of knowledge concerning need for immunization (loo%, data not shown separately from Figure 1). Medical records of 195 subjects interviewed (97%) were compared with their responses regarding immunization status. One claiming uncertainty of immunization had a history of influenza immunization and the remainder agreed with their medical records.

Never 0 0

Not sure

residents Number unimmunized past year

exceeded that of other groups, P< exceeded that of “never instructed”

It 19:: 15 31 126 0.00 I. or “not

Figure 1. Reason for non-immunization. A = Did not know I needed it; B = Did not want vaccination: C = Other miscellaneous; D = Heard it had bad side effects: E= Bad vaccine reaction in the past; F = Do no1 like vaccinations; G = Did not know where or how to get vaccination; H = Forgot about it; I = Too expensive; J = Too sick to get vaccination; K = No transportation. (NB. Figure contains multiple responses.)

170

Leading article Table

3. Reasonsfor noncomplianceamong study subjects* who previously acceptedvaccination

Reasonsfor vaccine noncompliance --__ A. Did not know of need B. Did not know whereto get it C. Did not want it (lack of motivation) D. Heard had bad sideeffects E. Experiencedbad sideeffects F. Did not like shots G. Too expensive H. Too sick I. No transportation J. Forgot about vaccination K. Other

Number of responses 28

13

15

7

33 23 29 20

16 11 14 10

15 7

7

7 8

3 3 4

25

12

202

Total

Percent response

100

* Seventy-eight of 82subjects whowerenot immunized lastyear,yetreceivedimmunization previously, answered this question. Forty-seven of the subjects gave more than one reason. Discussion

lation living in the Tampa Bay area at home was low (33%)9. Vaccine acceptance rate reportedin this presentcommunicationamong the NHCU residentsis similar, although the latter group of elderly may be assumed to be at a greater health risk requiring higher compliance. However, this rate of immunization amongstthe veterans(living at the NHCU or at home) is higher than the national average ( < 30%)s.Various factors uniqueto the veteran subjects might have contributed to the observedhigher immunization rates: the free availability of the vaccine to eligibleveterans, morefrequentexposureof the subjectsto medical facilities(dueto other disabilities)aswell as the recent effort of the Veterans’ Administration to promote “Preventive Health Program” which has been congressionallymandated”‘. However, thesecompliancerates are far below the target national goal of 6&80% vaccination of the high risk individuals with influenza vaccine6.‘*-1~ Only 26% of thosepatientswith yearly physician contact could recall an influenza recommendation.Several reasonscould explain this observationincluding limited patient recollection or low incidenceof physician recommendation. Misconception regarding the vaccine i.e., it is too expensiveor the vaccineproduces bad sidereactionswere commonamongstudy subjects and need to be corrected. Annual influenza immunization has been recom-

The highproportion of subjectsreporting physician’srecommendationastheir sourceof vaccination and the substantialgroup reporting lack of a physician’s recommendationas a reasonfor not beingvaccinatedunderscores the influenceof physiciansin patients’decisionsfor preventive medicine. Our data corroborate recently publishedobservationsof other+* and extend theseto the institutionalized elderly. In this study the recall biasof the subjectsappears to be minimal, as all but one of 195medical records,representing97% of the study subjects, agreedto the responsesgiven. However, the data reported may representselectionbias, as only mentally alert and medically eligible elderly wereadmittedto the study. Even so,the information gathered is consideredpertinent sinceit represents>83% of the NHCU residents. Exposureto massmediacampaigns,level of education or health alertnessmay be responsible for the 8-9% immunization rate among compliant subjectswithout physicianintervention, but these were not investigated in this study. It appearsthat dislikeof any sideeffects, unawarenessof vaccine requirement and generallack of motivation prevent continued prophylaxis amongst those that have previously acceptedimmunization. We have reported previously that influenza vaccineacceptancein the elderly veteran popu- mended since 1964 for persons at high risks.

Leading article especially the elderly, in an effort to reduce disease complications, hostpitalizations and specific mortality rates. Eligible veterans are given influenza vaccine free of charge upon request. The Swine Flu vaccine was associated with undesirable Guillain-Barr& syndrome (GBS)14.1S. Subsequent influenza vaccines did not have this increased frequency in GBS’4.‘5. The elderly veterans surveyed were not aware of these findings, which if known, could have improved their acceptance toward influenza vaccination. As with the home-living elderly veterans. the major factors influencing vaccine behavior of the institutionalized elderly also related to knowledge areas involving vaccine recommendations, cost. side effects, availability and lack of motivation9. It is important that relevant information about the vaccine regarding these issues be disseminated among the target group subjects. Educational and promotional campaigns may help dispel concerns among patients regarding the benefits. safety and efficacy of influenza vaccines’*. Physicians should use every opportunity to assess patients’ immunization status for preventive health care. Thus, more frequent physicians’ reminder for yearly influenza vaccination along with patient education and motivation would appear necessary to increase vaccination compliance in the elderly subjects studied. Finally, patient education measures to enhance medical compliance may not be necessarily expensive, as has been demonstrated by other investigators via mail and/or other means’y.2”

5. PreventIon and Control of Influenza: Part I, Vaccines. Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1989; 38: 297-311. 6. Influenza Vaccination Levels in Selected States Behavioral Risk Factor Surveillance System. 7.

x.

9

10

II 12

13.

14.

15.

Acknowledgment The authors are grateful to Mr. David Cameron and Mrs. Dawn Potvin for their technical assistance in carrying out this work. This study was supported partly by a VA Medical Research Fund on Aging.

16.

17.

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