- Email: [email protected]
Putting flu on the agenda
G Model
ARTICLE IN PRESS
JVAC-16724; No. of Pages 3
Vaccine xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Vaccine journal homepage: www.elsevier.com/locate/vaccine
SPI Track Putting flu on the agenda New voices, new partners Keywords: Communication Vaccination strategies Influenza commissioner Pharmacists Patient protection
At the Fifth ESWI Influenza Conference, the debate among scientists was not limited to talking about new developments in flu science. There are still other gaps that need to be filled. Reducing the flu burden also comes down to more funding and better vaccine and antiviral delivery, as well as broader messaging, gaining more support and, finally, achieving higher-performance flu prevention and care among those at risk, all over the world. Therefore, science should extend its traditional stakeholder scope and engage with more and new actors. A dedicated SPI session brought this topic under the spotlight. 1. Filling the gaps To keep flu on society’s agenda, scientists need to not only listen to their target audience and spread their message as efficiently as possible, translating scientific data into impactful, captivating stories containing all the arguments needed to convince the public, but also expand cooperation with a variety of partner actors who share a common interest, in this case reducing flu burden, and who also have the power to bridge funding, delivery and communication gaps. These “outside the flu science community” messengers can also be involved in bringing real and tangible change in building social consensus and help with the creation of a broader level of support. Therefore, more interaction and collaboration across borders is of the utmost importance.
(SAGE) recommendation for maternal influenza infection, one of the key challenges is that current vaccines are not available year round for programmes in developing countries. Also, the strain selection and manufacturing are not optimised for tropical and developing countries”, Klugman said. The Gates Foundation invests in randomised controlled trials to evaluate the efficacy of maternal flu immunisation. The Foundation also helps to build maternal flu immunisation platforms integrating antenatal care in developing countries. “We discovered that nearly 20% of HIV-infected women developed influenza during pregnancy. Our findings indicate vaccination has an enormous risk-mitigation effect on HIV patients. Its efficacy is 70%. And vaccination also protects the infant from 0 to 6 months of age.” With regard to paediatric influenza, the Gates Foundation explores better ways to protect young children from 6 to 24 months of age. “The question is now whether we can use the attenuated vaccine below the age of 2 years.” Therefore, the Gates Foundation funds, among other things, seasonal LAIV safety and evaluation trials. In respect of universal vaccination, the Gates Foundation looks at a number of technologies, one of them being the development of stalked-oriented vaccines. “One of the challenges is that there is no consensus on the meaning of universal. Annual flu vaccinations are also not deliverable by current immunisation systems in Low and Middle Income Countries. They also receive little external support for their vaccination programmes. The same goes for the pandemic threat. We support WHO with funding to give developing countries access to pandemic vaccines, again with a focus on children.” Advocacy is a critical part of the Gates Foundation. “Recommending vaccination is a two-way street. We are investing in studies in Low and Middle Income Countries. At the same time, what happens in developed countries is extremely important. What we do like to say is, develop a vaccine for the whole world, and we will help to fund your studies in the developing world, provided you make your vaccine available to the whole world through tiered pricing, and make it happen simultaneously in developed and non-developed countries.”
2. New funding principle 3. Media attention During the dedicated SPI track session, Keith Klugman, Director for Pneumonia in the Bill and Melinda Gates Foundation’s Global Health Division, presented the interest of the Gates Foundation in influenza protection. It is the Gates Foundation’s vision that every person deserves the chance to live a healthy and productive life. “We focus on the areas of greatest need and areas where we can have the greatest impact”, Klugman said. He explained the Pneumonia Department’s focus on children at risk in the weakest segment of the international community, the developing countries. “A substantial fraction of pneumonia cases in children and parents is due to secondary infection. Our main goal is to reduce the burden of seasonal influenza by increasing access to vaccines. For example, with regard to the adoption of the Strategic Advisory Group of Experts
During a pandemic, people need to understand the reality of the threat. Reaching the at-risk population is key. The lay press plays a key role in informing the public. The appointment of a single spokesman underpins the process of integrated crisis communication. Virologist Marc Van Ranst from KU Leuven University talked about his experience as Belgium’s official flu commissioner and government spokesman during the pandemic, also sharing tips and tricks. “The most important day in a crisis is day one”, said Van Ranst. “You need to control that one message by being omnipresent. And you should not shy away from live interviews, because they are the only moment where you have 100% control over content. In Belgium, we maintained the name Mexican flu all the way through
0264-410X/$ – see front matter http://dx.doi.org/10.1016/j.vaccine.2015.07.067
Please cite this article in press as: Russell C, et al. Putting flu on the agenda. New voices, new partners. Vaccine (2015), http://dx.doi.org/10.1016/j.vaccine.2015.07.067
G Model JVAC-16724; No. of Pages 3
ARTICLE IN PRESS SPI Track / Vaccine xxx (2015) xxx–xxx
2
our communication, because that was how people called H1N1 from day one.” In communicating difficult messages, it is handy to build up communication day after day. “It’s a way of avoiding headlines and suppressing possible panic”, Van Ranst said. “We knew WHO would announce its pandemic phase 4, meaning geographic spread. So we announced it beforehand in the media; it was news that ended up on page 4 of the newspapers. And by the time WHO actually announced phase 4, it was already old news, also ending up on page 4.” The same thing goes for the announcement of the first flu death: “When you have predicted there will be a flu death, the first real case is not such a big deal anymore, just because you predicted it.” Van Ranst attended the first eight funerals of people who died. “People have to know you care”, he said. During the pandemic, the Belgian flu commissioner never looked to use advertising. “We had no media budget. Moreover, people hate advertising. Instead we relied on good media relations. But in order to make media work for you in times of crisis, you have to work in advance and engage in a trusted relationship.” It is all about respect and reciprocity: “If you are nice to a journalist in times they need you, they will grant you a service when you need them”, Van Ranst said. “It is also very important to listen to the public’s voice, the talking points of the day. Therefore, we analysed all questions getting through to our call centre. A few hours of listening sufficed to assess that day’s information need. And we always adjusted our daily communication content to that need.” Van Ranst is convinced that difficult questions and media attention are easier to control in a small country like Belgium with its relatively narrow press landscape. What works in one country does not necessarily work in another. But the message that much depends on pre-existing relationships is universal. Furthermore, when working on a crisis with a team, you quickly learn who is stress-resilient and who is not. “Every team should be battle-tested first. And when you can put a little bit of humour in your work, you are able to survive a lot.”
4. Pharmacists lend a hand Can pharmacists play a role in vaccination strategies? Isabel Jacinto from the Portuguese National Association of Pharmacists (ANF) shed some light on the Portuguese experience. Since 2007, new legislation has allowed pharmacies to expand their scope of activity to new areas, including vaccination not included in the National Vaccination Plan. In 2008, the ANF responded with an extensive training programme based on the American Pharmacists’ Association Certificate Training Programme, and the rolling out of a specific intervention model and recommendations to support pharmacies and pharmacists in the provision of this new service, including an intervention protocol in case of an anaphylactic event, closely followed by a first national pharmacy-based influenza immunisation campaign in the 2008–2009 season. This immunisation campaign focused on raising public awareness about the availability of the service and informing target groups about influenza and the benefits of immunisation. The pharmacy-based immunisation delivery service was funded by the ANF, which also co-funded the organisation and implementation of the training programme. “Each pharmacy paid a fee of approximately EUR 200 per pharmacist attending the course. Each pharmacy also paid for life support and epinephrine to be kept at the pharmacy.” “Currently more than 2100 pharmacies provide a vaccination service. More than 3600 Portuguese pharmacists are certified for administering vaccines”, said Jacinto. The pharmacists’ intervention follows two possible paths. Risk patients without prescription are informed about influenza, preventive measures and the benefits of immunisation. They are also referred to a doctor. Patients who already have a prescription are dispensed the vaccine and
offered the option of being immunised at the pharmacy. When they decide to do so, the immunisation is delivered according to procedure and recorded to document the intervention. In 2011–2012, on average 230 flu shots were administered per pharmacy. According to the National Institute of Health in its Report of Influenza Vaccine Coverage in Portugal in 2011–2012, 55.1% of all flu shots were administered through the network of pharmacies, 22.1% were administered in health centres, another 7% at work and 6.5% in nursing centres. “The patients’ preference for pharmacies is clearly demonstrated in evidence-based studies over 4 consecutive years. Pharmacies provide a network close to the population, and this has big advantages”, said Jacinto. “They provide not only accessibility and geographical distribution, but also extended opening hours and thus convenience in the eyes of the patient. Furthermore, the involvement of pharmacies and pharmacists helps to build trust in vaccination.” Jacinto also talked about present-day challenges. “The difficult political, economic and social environment Portugal is currently experiencing results in the need to control public health expenditure and at the same time improve healthcare efficiency”, she said. The Portuguese government decided to provide free vaccines to individuals over 65 years of age in healthcare centres. The Portuguese press commented on this, focusing on the EUR 4 million budget cost of the measure, but forgetting about the resulting savings in health and indirect social costs. “The Portuguese influenza coverage rate among the elderly in 2012–2013 was 44.9%. Therefore the WHO target of 75% still represents a challenge and an opportunity for Portuguese pharmacies. Last July, the Health Minister and ANF signed an agreement focused on new incentives for pharmacies’ cooperation with public objectives, including vaccination services. This agreement foresees an independent evaluation of services provided by pharmacies in order to determine their value for the health system and possible future remuneration schemes in those fields. The implementation of this agreement represents also an opportunity to reshape pharmacy cooperation in public health and reinforce commitments that can succeed in more health promotion and disease prevention. “Portuguese pharmacies are committed with these objectives and, as in the past, available to enlarge services, namely in vaccination, and be scrutinised about their added value”, said Jacinto. Every country should think about the best ways to overcome the hurdles hindering vaccination rates from going up. The Portugal case exemplifies novel ways of doctors and pharmacists working together, as do similar approaches in the UK and Ireland; even if some general practitioners or nurses may be shocked by the idea of losing the monopoly on handling the syringe. “Also in Portugal, during the first year of operation, nurses resisted the idea, but not so anymore. Physicians did not oppose the administration of vaccines by pharmacists”, said Jacinto. Ted van Essen from the University Medical Centre Utrecht, The Netherlands, commented: “Collaborations such as these offer new opportunities. Trained pharmacists can administer a vaccine. They are healthcare professionals. The vaccine is perfectly safe, as safe as a glass of milk. The risk of an anaphylactic shock is a mere two cases out of a total of 4 million administered doses. And even then, pharmacists can be trained to deal with it. The most difficult to organise is the information exchange. Therefore, we should extend mental professional borders and remain focused on the end result to be achieved, a higher vaccination uptake, and collaborate as stakeholders.”
5. Patient becoming a client When talking about influencing the public’s behaviour in order to, for example, raise the vaccination uptake, we must remember that our behaviour towards health is quite strange. While good
Please cite this article in press as: Russell C, et al. Putting flu on the agenda. New voices, new partners. Vaccine (2015), http://dx.doi.org/10.1016/j.vaccine.2015.07.067
G Model JVAC-16724; No. of Pages 3
ARTICLE IN PRESS SPI Track / Vaccine xxx (2015) xxx–xxx
health is generally considered to be valuable, many people have little concern for their health until the moment they get sick. As a consequence, in the context of vaccination, healthcare providers see themselves confronted with people that do not see themselves as a patient in need, or as health dependent, but just as clients being offered a product for consumption, with the opinion of the healthcare provider being important, but also being just one opinion among many. The problem is that healthcare workers are trained to communicate with people being patients, but not with people behaving as clients. “Every context creates a unique relationship between people”, said Eugenijus Laurinaitis, from the Department of Psychiatry at Vilnius University, Lithuania. “This communication requires a lot of skills that are not part of training at University but are mastered every day, including by trying to do better than the master. Each of our actions is affected by conscious motivation. But there is also unconscious motivation, which (in a patient-healthcare worker relationship) is completely unknown not only to the healthcare worker, but also to the patient him/herself.” Our memory is always changing, and the way we remember things and add value shifts in time. So everyone constructs his/her own representation of reality, and “every person has his/her own truth.” Laurinaitis distinguished four systems that can determine our beliefs regarding health: the mechanical system, which sees decaying health as mechanics that wear out; the energy system, which links sickness to a lacklustre life; the interpersonal system, which relates sickness to the others’ behaviour; and the transcendental system, which sees sickness as a punishment from something of an alien order. “Given this context, we have to find something that unites patient and practitioner”, said Laurinaitis. What are the intervention strategies? “We have to look for a binding element, something we have in common, in order to build rapport. Only the patient will make a decision for him/herself. And our knowledge about what that decision will influence is very superficial, for example persuading someone else to do something or to behave in a certain manner. People feel what you feel. Therefore, in order to be able to really persuade someone, we ourselves have to believe in what we want to persuade the other about. And we also have to know every counter-argument the patient might develop in advance. And thus, practitioners not only need technical information on flu, but also need to be trained in practical communication skills. When it comes to advocating vaccination, it is the practitioner who is doing the job. Everybody is talking about the job, but it comes down to helping the person in the job and equipping GPs with tools and information”, Laurinaitis said. Laurinaitis also elaborated on the Motivational Interview approach. Motivational Interviewing is grounded in a respectful stance with a focus on building rapport in the initial stages of the counselling relationship. A central concept in Motivational Interviewing is the identification, examination and resolution of ambivalence about changing behaviour. Ambivalence, feeling two ways about behaviour change, is seen as a natural part of the change process. Ambivalence, in some way, predicts “readiness for change.” The skilful Motivational Interview practitioner is attuned to client ambivalence and cleverly utilises techniques and strategies that are responsive to the client. “Motivational Interviewing
3
is designed to strengthen an individual’s own motivation for and movement towards a specific goal by eliciting and exploring the person’s own arguments for change”, Laurinaitis said. “The spirit of the Motivational Interview is based on three elements: collaboration between the practitioner and the client; evoking or drawing out the client’s ideas about change; and emphasising the autonomy of the client.” 6. SPI lessons learned Scientists need to expand cooperation with a variety of partner actors who share a common interest, reducing flu burden, and who have the power to bridge funding, delivery and communication gaps. The lay press plays a key role in informing the public. If you are nice to a journalist in times the journalist needs you, he or she will grant you a service in your own time of need. Building media relations is all about respect and reciprocity. Every country should think of the best ways to tackle the hurdles hindering vaccination rates from going up. The Portugal case exemplifies novel ways of doctors and pharmacists working together, as do similar approaches in the UK and Ireland. Collaborations such as these offer new opportunities. In the context of vaccination, healthcare providers see themselves confronted with people that do not see themselves as a patient in need, but as clients being offered a product for consumption. The problem is that healthcare workers are trained to communicate with people being patients, but not with people behaving as clients. Therefore, practitioners need not only technical information on flu, but also to be trained in practical communication skills, such as Motivational Interviewing techniques. Conflict of interest: The authors have declared that there is no conflict of interest. Colin Russell ∗ University of Cambridge, Cambridge, United Kingdom Keith Klugman Bill & Melinda Gates Foundation, United States Marc Van Ranst KU Leuven, Leuven, Belgium Isabel Jacinto National Association of Pharmacies, Portugal Eugenijus Laurinaitis University of Vilnius, Vilnius, Lithuania ∗ Corresponding
author at: Department of Veterinary Medicine, University of Cambridge, Madingley Road, Cambridge CB3 0ES, United Kingdom. E-mail address: [email protected] (C. Russell) Available online xxx
Please cite this article in press as: Russell C, et al. Putting flu on the agenda. New voices, new partners. Vaccine (2015), http://dx.doi.org/10.1016/j.vaccine.2015.07.067
ARTICLE IN PRESS
JVAC-16724; No. of Pages 3
Vaccine xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Vaccine journal homepage: www.elsevier.com/locate/vaccine
SPI Track Putting flu on the agenda New voices, new partners Keywords: Communication Vaccination strategies Influenza commissioner Pharmacists Patient protection
At the Fifth ESWI Influenza Conference, the debate among scientists was not limited to talking about new developments in flu science. There are still other gaps that need to be filled. Reducing the flu burden also comes down to more funding and better vaccine and antiviral delivery, as well as broader messaging, gaining more support and, finally, achieving higher-performance flu prevention and care among those at risk, all over the world. Therefore, science should extend its traditional stakeholder scope and engage with more and new actors. A dedicated SPI session brought this topic under the spotlight. 1. Filling the gaps To keep flu on society’s agenda, scientists need to not only listen to their target audience and spread their message as efficiently as possible, translating scientific data into impactful, captivating stories containing all the arguments needed to convince the public, but also expand cooperation with a variety of partner actors who share a common interest, in this case reducing flu burden, and who also have the power to bridge funding, delivery and communication gaps. These “outside the flu science community” messengers can also be involved in bringing real and tangible change in building social consensus and help with the creation of a broader level of support. Therefore, more interaction and collaboration across borders is of the utmost importance.
(SAGE) recommendation for maternal influenza infection, one of the key challenges is that current vaccines are not available year round for programmes in developing countries. Also, the strain selection and manufacturing are not optimised for tropical and developing countries”, Klugman said. The Gates Foundation invests in randomised controlled trials to evaluate the efficacy of maternal flu immunisation. The Foundation also helps to build maternal flu immunisation platforms integrating antenatal care in developing countries. “We discovered that nearly 20% of HIV-infected women developed influenza during pregnancy. Our findings indicate vaccination has an enormous risk-mitigation effect on HIV patients. Its efficacy is 70%. And vaccination also protects the infant from 0 to 6 months of age.” With regard to paediatric influenza, the Gates Foundation explores better ways to protect young children from 6 to 24 months of age. “The question is now whether we can use the attenuated vaccine below the age of 2 years.” Therefore, the Gates Foundation funds, among other things, seasonal LAIV safety and evaluation trials. In respect of universal vaccination, the Gates Foundation looks at a number of technologies, one of them being the development of stalked-oriented vaccines. “One of the challenges is that there is no consensus on the meaning of universal. Annual flu vaccinations are also not deliverable by current immunisation systems in Low and Middle Income Countries. They also receive little external support for their vaccination programmes. The same goes for the pandemic threat. We support WHO with funding to give developing countries access to pandemic vaccines, again with a focus on children.” Advocacy is a critical part of the Gates Foundation. “Recommending vaccination is a two-way street. We are investing in studies in Low and Middle Income Countries. At the same time, what happens in developed countries is extremely important. What we do like to say is, develop a vaccine for the whole world, and we will help to fund your studies in the developing world, provided you make your vaccine available to the whole world through tiered pricing, and make it happen simultaneously in developed and non-developed countries.”
2. New funding principle 3. Media attention During the dedicated SPI track session, Keith Klugman, Director for Pneumonia in the Bill and Melinda Gates Foundation’s Global Health Division, presented the interest of the Gates Foundation in influenza protection. It is the Gates Foundation’s vision that every person deserves the chance to live a healthy and productive life. “We focus on the areas of greatest need and areas where we can have the greatest impact”, Klugman said. He explained the Pneumonia Department’s focus on children at risk in the weakest segment of the international community, the developing countries. “A substantial fraction of pneumonia cases in children and parents is due to secondary infection. Our main goal is to reduce the burden of seasonal influenza by increasing access to vaccines. For example, with regard to the adoption of the Strategic Advisory Group of Experts
During a pandemic, people need to understand the reality of the threat. Reaching the at-risk population is key. The lay press plays a key role in informing the public. The appointment of a single spokesman underpins the process of integrated crisis communication. Virologist Marc Van Ranst from KU Leuven University talked about his experience as Belgium’s official flu commissioner and government spokesman during the pandemic, also sharing tips and tricks. “The most important day in a crisis is day one”, said Van Ranst. “You need to control that one message by being omnipresent. And you should not shy away from live interviews, because they are the only moment where you have 100% control over content. In Belgium, we maintained the name Mexican flu all the way through
0264-410X/$ – see front matter http://dx.doi.org/10.1016/j.vaccine.2015.07.067
Please cite this article in press as: Russell C, et al. Putting flu on the agenda. New voices, new partners. Vaccine (2015), http://dx.doi.org/10.1016/j.vaccine.2015.07.067
G Model JVAC-16724; No. of Pages 3
ARTICLE IN PRESS SPI Track / Vaccine xxx (2015) xxx–xxx
2
our communication, because that was how people called H1N1 from day one.” In communicating difficult messages, it is handy to build up communication day after day. “It’s a way of avoiding headlines and suppressing possible panic”, Van Ranst said. “We knew WHO would announce its pandemic phase 4, meaning geographic spread. So we announced it beforehand in the media; it was news that ended up on page 4 of the newspapers. And by the time WHO actually announced phase 4, it was already old news, also ending up on page 4.” The same thing goes for the announcement of the first flu death: “When you have predicted there will be a flu death, the first real case is not such a big deal anymore, just because you predicted it.” Van Ranst attended the first eight funerals of people who died. “People have to know you care”, he said. During the pandemic, the Belgian flu commissioner never looked to use advertising. “We had no media budget. Moreover, people hate advertising. Instead we relied on good media relations. But in order to make media work for you in times of crisis, you have to work in advance and engage in a trusted relationship.” It is all about respect and reciprocity: “If you are nice to a journalist in times they need you, they will grant you a service when you need them”, Van Ranst said. “It is also very important to listen to the public’s voice, the talking points of the day. Therefore, we analysed all questions getting through to our call centre. A few hours of listening sufficed to assess that day’s information need. And we always adjusted our daily communication content to that need.” Van Ranst is convinced that difficult questions and media attention are easier to control in a small country like Belgium with its relatively narrow press landscape. What works in one country does not necessarily work in another. But the message that much depends on pre-existing relationships is universal. Furthermore, when working on a crisis with a team, you quickly learn who is stress-resilient and who is not. “Every team should be battle-tested first. And when you can put a little bit of humour in your work, you are able to survive a lot.”
4. Pharmacists lend a hand Can pharmacists play a role in vaccination strategies? Isabel Jacinto from the Portuguese National Association of Pharmacists (ANF) shed some light on the Portuguese experience. Since 2007, new legislation has allowed pharmacies to expand their scope of activity to new areas, including vaccination not included in the National Vaccination Plan. In 2008, the ANF responded with an extensive training programme based on the American Pharmacists’ Association Certificate Training Programme, and the rolling out of a specific intervention model and recommendations to support pharmacies and pharmacists in the provision of this new service, including an intervention protocol in case of an anaphylactic event, closely followed by a first national pharmacy-based influenza immunisation campaign in the 2008–2009 season. This immunisation campaign focused on raising public awareness about the availability of the service and informing target groups about influenza and the benefits of immunisation. The pharmacy-based immunisation delivery service was funded by the ANF, which also co-funded the organisation and implementation of the training programme. “Each pharmacy paid a fee of approximately EUR 200 per pharmacist attending the course. Each pharmacy also paid for life support and epinephrine to be kept at the pharmacy.” “Currently more than 2100 pharmacies provide a vaccination service. More than 3600 Portuguese pharmacists are certified for administering vaccines”, said Jacinto. The pharmacists’ intervention follows two possible paths. Risk patients without prescription are informed about influenza, preventive measures and the benefits of immunisation. They are also referred to a doctor. Patients who already have a prescription are dispensed the vaccine and
offered the option of being immunised at the pharmacy. When they decide to do so, the immunisation is delivered according to procedure and recorded to document the intervention. In 2011–2012, on average 230 flu shots were administered per pharmacy. According to the National Institute of Health in its Report of Influenza Vaccine Coverage in Portugal in 2011–2012, 55.1% of all flu shots were administered through the network of pharmacies, 22.1% were administered in health centres, another 7% at work and 6.5% in nursing centres. “The patients’ preference for pharmacies is clearly demonstrated in evidence-based studies over 4 consecutive years. Pharmacies provide a network close to the population, and this has big advantages”, said Jacinto. “They provide not only accessibility and geographical distribution, but also extended opening hours and thus convenience in the eyes of the patient. Furthermore, the involvement of pharmacies and pharmacists helps to build trust in vaccination.” Jacinto also talked about present-day challenges. “The difficult political, economic and social environment Portugal is currently experiencing results in the need to control public health expenditure and at the same time improve healthcare efficiency”, she said. The Portuguese government decided to provide free vaccines to individuals over 65 years of age in healthcare centres. The Portuguese press commented on this, focusing on the EUR 4 million budget cost of the measure, but forgetting about the resulting savings in health and indirect social costs. “The Portuguese influenza coverage rate among the elderly in 2012–2013 was 44.9%. Therefore the WHO target of 75% still represents a challenge and an opportunity for Portuguese pharmacies. Last July, the Health Minister and ANF signed an agreement focused on new incentives for pharmacies’ cooperation with public objectives, including vaccination services. This agreement foresees an independent evaluation of services provided by pharmacies in order to determine their value for the health system and possible future remuneration schemes in those fields. The implementation of this agreement represents also an opportunity to reshape pharmacy cooperation in public health and reinforce commitments that can succeed in more health promotion and disease prevention. “Portuguese pharmacies are committed with these objectives and, as in the past, available to enlarge services, namely in vaccination, and be scrutinised about their added value”, said Jacinto. Every country should think about the best ways to overcome the hurdles hindering vaccination rates from going up. The Portugal case exemplifies novel ways of doctors and pharmacists working together, as do similar approaches in the UK and Ireland; even if some general practitioners or nurses may be shocked by the idea of losing the monopoly on handling the syringe. “Also in Portugal, during the first year of operation, nurses resisted the idea, but not so anymore. Physicians did not oppose the administration of vaccines by pharmacists”, said Jacinto. Ted van Essen from the University Medical Centre Utrecht, The Netherlands, commented: “Collaborations such as these offer new opportunities. Trained pharmacists can administer a vaccine. They are healthcare professionals. The vaccine is perfectly safe, as safe as a glass of milk. The risk of an anaphylactic shock is a mere two cases out of a total of 4 million administered doses. And even then, pharmacists can be trained to deal with it. The most difficult to organise is the information exchange. Therefore, we should extend mental professional borders and remain focused on the end result to be achieved, a higher vaccination uptake, and collaborate as stakeholders.”
5. Patient becoming a client When talking about influencing the public’s behaviour in order to, for example, raise the vaccination uptake, we must remember that our behaviour towards health is quite strange. While good
Please cite this article in press as: Russell C, et al. Putting flu on the agenda. New voices, new partners. Vaccine (2015), http://dx.doi.org/10.1016/j.vaccine.2015.07.067
G Model JVAC-16724; No. of Pages 3
ARTICLE IN PRESS SPI Track / Vaccine xxx (2015) xxx–xxx
health is generally considered to be valuable, many people have little concern for their health until the moment they get sick. As a consequence, in the context of vaccination, healthcare providers see themselves confronted with people that do not see themselves as a patient in need, or as health dependent, but just as clients being offered a product for consumption, with the opinion of the healthcare provider being important, but also being just one opinion among many. The problem is that healthcare workers are trained to communicate with people being patients, but not with people behaving as clients. “Every context creates a unique relationship between people”, said Eugenijus Laurinaitis, from the Department of Psychiatry at Vilnius University, Lithuania. “This communication requires a lot of skills that are not part of training at University but are mastered every day, including by trying to do better than the master. Each of our actions is affected by conscious motivation. But there is also unconscious motivation, which (in a patient-healthcare worker relationship) is completely unknown not only to the healthcare worker, but also to the patient him/herself.” Our memory is always changing, and the way we remember things and add value shifts in time. So everyone constructs his/her own representation of reality, and “every person has his/her own truth.” Laurinaitis distinguished four systems that can determine our beliefs regarding health: the mechanical system, which sees decaying health as mechanics that wear out; the energy system, which links sickness to a lacklustre life; the interpersonal system, which relates sickness to the others’ behaviour; and the transcendental system, which sees sickness as a punishment from something of an alien order. “Given this context, we have to find something that unites patient and practitioner”, said Laurinaitis. What are the intervention strategies? “We have to look for a binding element, something we have in common, in order to build rapport. Only the patient will make a decision for him/herself. And our knowledge about what that decision will influence is very superficial, for example persuading someone else to do something or to behave in a certain manner. People feel what you feel. Therefore, in order to be able to really persuade someone, we ourselves have to believe in what we want to persuade the other about. And we also have to know every counter-argument the patient might develop in advance. And thus, practitioners not only need technical information on flu, but also need to be trained in practical communication skills. When it comes to advocating vaccination, it is the practitioner who is doing the job. Everybody is talking about the job, but it comes down to helping the person in the job and equipping GPs with tools and information”, Laurinaitis said. Laurinaitis also elaborated on the Motivational Interview approach. Motivational Interviewing is grounded in a respectful stance with a focus on building rapport in the initial stages of the counselling relationship. A central concept in Motivational Interviewing is the identification, examination and resolution of ambivalence about changing behaviour. Ambivalence, feeling two ways about behaviour change, is seen as a natural part of the change process. Ambivalence, in some way, predicts “readiness for change.” The skilful Motivational Interview practitioner is attuned to client ambivalence and cleverly utilises techniques and strategies that are responsive to the client. “Motivational Interviewing
3
is designed to strengthen an individual’s own motivation for and movement towards a specific goal by eliciting and exploring the person’s own arguments for change”, Laurinaitis said. “The spirit of the Motivational Interview is based on three elements: collaboration between the practitioner and the client; evoking or drawing out the client’s ideas about change; and emphasising the autonomy of the client.” 6. SPI lessons learned Scientists need to expand cooperation with a variety of partner actors who share a common interest, reducing flu burden, and who have the power to bridge funding, delivery and communication gaps. The lay press plays a key role in informing the public. If you are nice to a journalist in times the journalist needs you, he or she will grant you a service in your own time of need. Building media relations is all about respect and reciprocity. Every country should think of the best ways to tackle the hurdles hindering vaccination rates from going up. The Portugal case exemplifies novel ways of doctors and pharmacists working together, as do similar approaches in the UK and Ireland. Collaborations such as these offer new opportunities. In the context of vaccination, healthcare providers see themselves confronted with people that do not see themselves as a patient in need, but as clients being offered a product for consumption. The problem is that healthcare workers are trained to communicate with people being patients, but not with people behaving as clients. Therefore, practitioners need not only technical information on flu, but also to be trained in practical communication skills, such as Motivational Interviewing techniques. Conflict of interest: The authors have declared that there is no conflict of interest. Colin Russell ∗ University of Cambridge, Cambridge, United Kingdom Keith Klugman Bill & Melinda Gates Foundation, United States Marc Van Ranst KU Leuven, Leuven, Belgium Isabel Jacinto National Association of Pharmacies, Portugal Eugenijus Laurinaitis University of Vilnius, Vilnius, Lithuania ∗ Corresponding
author at: Department of Veterinary Medicine, University of Cambridge, Madingley Road, Cambridge CB3 0ES, United Kingdom. E-mail address: [email protected] (C. Russell) Available online xxx
Please cite this article in press as: Russell C, et al. Putting flu on the agenda. New voices, new partners. Vaccine (2015), http://dx.doi.org/10.1016/j.vaccine.2015.07.067