American Journal of Infection Control 42 (2014) 294-9

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American Journal of Infection Control

American Journal of Infection Control

journal homepage: www.ajicjournal.org

Major article

Employee influenza vaccination in residential care facilities Bettye A. Apenteng PhD a, *, Samuel T. Opoku MBChB b a b

Department of Health Policy and Management, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, GA Department of Health Services Research and Administration, College of Public Health, University of Nebraska Medical Center, Omaha, NE

Key Words: Vaccination policies National Survey of Residential Care Facilities Health care workers Assisted living facilities Long-term care

Background: The organizational literature on infection control in residential care facilities is limited. Using a nationally representative dataset, we examined the organizational factors associated with implementing at least 1 influenza-related employee vaccination policy/program, as well as the effect of vaccination policies on health care worker (HCW) influenza vaccine uptake in residential care facilities. Methods: The study was a cross-sectional study using data from the 2010 National Survey of Residential Care Facilities. Multivariate logistic regression analysis was used to address the study’s objectives. Results: Facility size, director’s educational attainment, and having a written influenza pandemic preparedness plan were significantly associated with the implementation of at least 1 influenza-related employee vaccination policy/program, after controlling for other facility-level factors. Recommending vaccination to employees, providing vaccination on site, providing vaccinations to employees at no cost, and requiring vaccination as a condition of employment were associated with higher employee influenza vaccination rates. Conclusion: Residential care facilities can improve vaccination rates among employees by adopting effective employee vaccination policies. Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Influenza is the leading cause of vaccine-preventable deaths in the United States, and more than 200,000 people each year are hospitalized for influenza.1,2 Elderly persons, children, and immunocompromised individuals are particularly vulnerable to complications of influenza.2 Vaccination is the most effective way to prevent infection associated with the disease.3 Influenza vaccination is recommended for all health care workers (HCWs), including long-term care workers because of their close interaction with the sick and elderly. Despite widespread advocacy for HCW influenza vaccination, vaccination rates remain well below the Centers for Disease Control and Prevention (CDC) Healthy People 2020 goal of 90%.4 In 2006, US HCW vaccination rates were between 23% and 37%.5 After the H1NI pandemic, the CDC estimates that in 2010, 64% of HCWs received either the seasonal influenza vaccine or the vaccine targeting the H1N1 strain.3 HCW do not get vaccinated for influenza for a number of reasons, including fear of side effects, allergic responses to the vaccine, lack of faith in the vaccine’s efficacy, religious beliefs against vaccination, lack of time, and low assessment of individual risk.6-13 There is * Address correspondence to Bettye A. Apenteng, PhD, Department of Health Policy and Management, Jiann-Ping Hsu College of Public Health, Georgia Southern University, PO Box 8015, Statesboro, GA 30460-8149. E-mail address: [email protected] (B.A. Apenteng). Conflict of interest: None to report.

evidence suggesting that prioritizing the implementation of HCW vaccination policies can yield significant societal and organizational cost savings.3,14 In a study examining the cost-effectiveness of vaccination of working adults, Nichol et al15 reported an association between vaccination and decreased likelihood of illness, fewer sick days, and fewer doctor visits, all culminating in an average cost savings of $46.85 (in 1994 dollars) per vaccinated individual. Other studies have found an association between vaccination and reduced workplace absenteeism and use of sick days.16,17 Studies exploring organizational efforts to boost HCW vaccination rates suggest that health care organizations can improve vaccination rates among HCWs by removing administrative barriers to vaccination.7 Such efforts could include providing education on the importance of vaccination, providing vaccines for free or at reduced cost, providing vaccinations at accessible locations and convenient times, as well as providing incentives to HCWs to encourage vaccination.7,18,19 In 1 study, institution of a policy of mandatory vaccination with consequences resulted in improved compliance, compared with a mandate without consequences.20 However, others have expressed concern regarding the ethical implications of mandates and instead suggested the use of incentives and sanctions to improve HCW vaccination compliance.21 HCW vaccination is particularly important for organizations that provide health care to the elderly. Although it has not been

0196-6553/$36.00 - Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2013.09.021

B.A. Apenteng, S.T. Opoku / American Journal of Infection Control 42 (2014) 294-9

conclusively established that HCW vaccination prevents influenza among seniors residing in long-term facilities, there is evidence suggesting that HCW vaccination in long-term care facilities reduces morbidity and mortality in the elderly.22-26 Historically, vaccination rates among long-term care workers have been low, however.27 During the 2009-2010 influenza season, the vaccination rate for seasonal influenza among long-term care staff was 54%, compared with 62% in all HCWs.28 Long-term care organizations have been encouraged to institute influenza preparedness and vaccination programs and policies for their staff.29 Although several organizational studies have characterized and examined the effectiveness of vaccination programs in long-term care facilities,19,23,30,31 these studies focused primarily on nursing homes and long-term care hospitals; research focusing on residential care facilities is lacking. In the present study, using data from the first-ever National Survey of Residential Care Facilities (NSRCF), we sought to examine the organizational factors associated with implementing an employee influenza vaccination policy/ program and to evaluate the effect of vaccination policies/programs on HCW influenza vaccine uptake rates in US residential care facilities. METHODS Study design, sample, and data Data for this study were obtained from the 2010 NSRCF, the first nationally representative survey of US residential care facilities. Until this survey, nationally representative data on residential care facilities were lacking.32 Facilities surveyed in the NSRCF included licensed, registered, or certified assisted-living residences; board and care homes; congregate care; enriched housing programs; homes for the aged; personal care homes; and shared housing establishments.32,33 The survey was further restricted to those facilities with 4 or more beds that provided room and board with 2 or more meals a day, provided help with personal care needs and health-related services, and provided round-the-clock supervision.32,33 A total of 2,302 facilities were surveyed, the majority of which served the elderly. Facilities exclusively serving the mentally ill or the developmentally disabled were excluded.33 Only facility directors or their designated staff were interviewed for this survey. The NSRCF used a stratified 2-stage probability sample design. The first and second stages involved sampling of facilities and residents, respectively. The weighted response rate for the survey was 81%. A detailed discussion of the methodology for this survey is available at http://www.cdc.gov/nchs/nsrcf.htm. In the present study, we used only publicly available data from the facility-level survey. Measures Dependent variables The dependent variables in this study were a binary variable indicating whether or not a facility had at least 1 influenza-related employee vaccination policy/program in place and another binary variable indicating whether a facility had achieved a high influenza employee vaccination uptake rate in the last year. The Joint Commission recommends a vaccination rate of at least 80% to achieve the herd immunity necessary to reduce influenza-related nosocomial infections in health care facilities.34 Following Joint Commission recommendations, facilities with high employee influenza vaccination uptakes were defined as those reporting an employee influenza vaccination rate of >80%. The cutpoint was set at 81% rather than 80% because of data constraints; the NSRCF reported data on employee vaccination rates in categories, and facilities reporting 80% vaccination rates were placed in the 61%-80% category.

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Covariates The study defined organizational characteristics, including structural characteristics, staffing-related characteristics, patient/ resident composition, and organizational commitment to preparedness. The following factors were examined as potential covariates: ownership type; facility size; type of care provided (ie, respite care, adult day services, or care for mental health and developmental disabilities); whether or not the facility accepted Medicaid; certification and educational attainment of the director; total personal care aide, licensed practical/vocational nurse (LPN/LVNs), and registered nurse (RN) hours; and the proportions of females and white residents, as well as the proportion of adults age >84 years served by the facility. Also included was a variable indicating whether or not an organization had a written influenza pandemic preparedness plan. For both multivariate models, only factors that were statistically associated with the dependent variable on bivariate analysis (P < .05) were included in the final model as covariates. The primary independent variables in the model assessing the factors influencing high HCW vaccination uptake rates were binary indicators for 7 employee vaccination policies related to influenza: recommending vaccination to employees; providing vaccinations on site; providing vaccinations to employees at no cost; requiring vaccination (or contraindication) as a condition of employment; providing vaccines at reduced cost; providing incentives for employee vaccination; and having a patient restriction policy for sick employees. The NSRCF collected data on the use of these 7 vaccination policies only. Analyses In model 1, logistic regression was used to assess the organizational factors influencing the implementation of at least 1 employee vaccination policy/program. In model 2, an ordinal logistic regression model was initially chosen to examine the effect of various vaccination policies on employee vaccination uptake rates. However, the results from the Brant test for proportional odds assumption indicated that the proportional odds assumption was violated. Thus, a logistic regression was fit instead, and results from that model are presented here. As indicated earlier, this second model was used to examine the policies associated with high employee vaccination rates, defined as vaccination uptake rates of >80%. The variable indicating whether or not a facility was located in a metropolitan statistical area was dropped from all analyses because of a significant number of missing data. Statistical significance was defined at the P < .05 level. A correlation analysis was conducted for both models. The correlation coefficient of all paired variables was lower than the standard cutoff point of 0.65, indicating the absence of multicolinearity in the data. The regression models were weighted to account for the complex sampling design of the NSRCF and to obtain nationally representative parameter estimates. Analyses were performed using Stata 13.0 (StataCorp, College Station, TX). RESULTS Facility characteristics Table 1 provides a descriptive summary of the characteristics of the facilities in the study sample. The majority of facilities (82.4%) were for-profit owned. Approximately one-third (37.7%) were part of a chain. The majority (49.6%) had 4-10 beds; only 6.7% facilities had more than 100 beds. The facilities were located mostly in metropolitan statistical areas (80.5%), and almost one-half (49.8%) accepted Medicaid patients.

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Table 1 Facility characteristics

Variable

Weighted n*

Organizational structural characteristics For-profit ownership 31,134 Part of a chain 31,134 Facility size 31,134 Small (4-10 beds) Medium (11-25 beds) Large (26-100 beds) Extra large (>100 beds) Located in a metropolitan 29,042 statistical area Accepts Medicaid patients 31,082 31,134 Provides adult day health and day care services to nonresidents Provides short-term respite 31,134 care Provides services to at 31,134 least 1 person with developmental disability Staffing-related factors 31,089 Director has certificate or license related to managing facilities for older people Director’s highest educational 30,991 attainment Less than college Some college College graduate Postgraduate Personal care aide total hours 31,038 in the past week LPN/LVN total hours in the 31,065 past week RN total hours in the 31,075 past week Patient characteristics Proportion of residents 31,134 age
85 years Proportion of residents 31,134 who are white Proportion of female residents 31,134 Organizational commitment to preparedness Management plan for 31,030 influenza pandemic No, not started Yes, in progress Yes, completed Dependent variables Number of vaccination 31,040 policies/programs 0 1 2 3 4 5 Percentage of employees 31,134 receiving flu shot last year, % 0 1-20 21-40 41-60 61-80 81-99 100

Mean (SD)

Frequency (weighted %) 25,648 (82.4) 11,724 (37.7) 15,439 4,947 8,656 2,092 23,382

(49.6) (15.9) (27.8) (6.7) (80.5)

11,472 (49.8) 3,546 (11.39)

8,282 (26.6) 12,049 (38.7)

25,947 (83.5)

4,952 6,823 13,721 5,495

(16.0) (22.0) (44.3) (17.7)

272.6 (244.0) 19.4 (36.4) 11.0 (20.6)

48.8 (20.9)

predominantly older, white, and female residents. More than onethird of the facilities (40.8%) did not have a management plan in place for influenza pandemic, whereas 82.4% had at least 1 influenza vaccination policy/program in place for their employees. Approximately 10% of facilities reported that none of their employees had received the influencza vaccine in the preceding year, whereas 32.5% reported a 100% vaccination rate for all employees. Model 1: Factors associated with having at least 1 employee vaccination policy/program Results from the logistic regression model indicated that the following organizational factors were significantly associated with having at least 1 employee vaccination policy/program: chain ownership, facility size, director’s educational attainment, and presence of a pandemic influenza management plan. Specifically, chain-owned residential care facilities were more likely to have at least 1 employee influenza vaccination policy/program in place (odds ratio [OR], 1.39; P < .05). Moreover, compared with small facilities (4-10 beds), medium (11-25 beds) and large facilities (26100 beds) were more likely to have an employee vaccination policy/ program in place (OR, 1.73; P < .01 and OR, 2.01; P < .01, respectively). Facilities with directors with a college degree were also more likely to have a vaccination policy/program in place (OR, 2.00; P < .01), compared with those facilities with directors who were not college-educated. In addition, compared with facilities with no influenza preparedness plan, facilities with a written influenza pandemic preparedness plan were more likely to have implemented at least 1 employee vaccination policy/program. Facilities with a written plan in progress were 3 times likely to have at least 1 employee vaccination policy/program (OR, 3.15l; P < .001), while those with a completed plan were almost twice as likely to have any employee vaccination policy/program in place (OR, 1.94; P < .001). Results from the logistic regression model are summarized in Table 2.

88.5 (21.6)

Model 2: Effects of employee vaccination policies on employee influenza vaccination rates

68.2 (25.0)

12,667 (40.8) 4,455 (14.4) 13,908 (44.8)

5,470 11,241 9,856 3,346 869 258

(17.6) (36.2) (31.8) (10.8) (2.8) (0.8)

3,313 2,860 2,493 4,600 3,286 4,453 10,129

(10.6) (9.2) (8.0) (14.8) (10.6) (14.3) (32.5)

*Weights were applied to approximate national estimates.

In more than 80% of facilities, the director that had a certificate or license related to managing facilities for the elderly. The majority of directors (62.0%) had at least a college degree. The mean total hours per week for personal care aides, LPN/LVNs and RNs were 272.6, 19.4, and 11.0 hours, respectively. The facilities served

Table 3 shows the extent of adoption of various vaccination policies in residential care facilities, stratified by employee uptake rates. The descriptive results suggest that whereas a higher proportion of facilities achieving a 100% influenza vaccination rate required proof of vaccination as a condition for employment, a higher proportion of facilities with employee influenza vaccination rates between 81% and 99% recommended vaccinations, provided vaccinations on site and for free, incentivized their staff for vaccination, and had a patient restriction policy in place for employees who developed flu-like symptoms. We sought to identify the vaccination policies independently associated with achieving a high employee influenza vaccination rate (81%-100%). Table 4 summarizes the results from our logistic regression model. After adjusting for confounding organizational factors, facilities achieving high employee influenza vaccination were more likely to recommend vaccination to staff (OR, 1.58; P < .001), offer vaccinations on site (OR, 1.46; P < .01), offer vaccinations for free (OR, 1.76; P < .001), provide staff with incentives for vaccination (OR, 1.53; P < .05), and require proof of vaccination or contraindication as a condition for employment (OR, 1.93; P < .001). Providing vaccines at a reduced cost and having a patient restriction policy for sick employees were not independently associated with employee influenza vaccination rates in the study sample. Other covariates statistically associated with high influenza vaccination uptake HCWs included facility size, provision of services to at least 1 person with developmental disabilities, total

B.A. Apenteng, S.T. Opoku / American Journal of Infection Control 42 (2014) 294-9 Table 2 Logistic regression model: factors associated with having at least 1 influenza-related employee vaccination policy/program in place Having at least 1 employee vaccination policy/program (reference, no plan) Variable

OR [SE]

95% CI

Organizational structural characteristics For profit ownership 1.05 [0.20] 0.72-1.54 Part of a chain 1.39 [0.23] 1.01-1.93 Facility size: reference, small (4-10 beds) Medium (11-25 beds) 1.73* [0.29] 1.25-2.41 Large (26-100 beds) 2.01* [0.45] 1.30-3.13 Extra large (>100 beds) 1.39 [0.56] 0.63-3.05 Provides short-term respite care 0.85 [0.16] 0.59-1.22 1.08 [0.18] 0.78-1.49 Provides services to at least 1 person with developmental disability Staffing-related factors Director’s highest educational attainment (reference, less than college) Some college 1.47 [0.37] 0.96-2.24 College graduate 2.00* [0.40] 1.35-2.98 Postgraduate 1.47 [0.37] 0.90-2.41 1.00 [0.001] 1.00-1.00 Personal care aide total hours per week LPN/LVN total hours per week 1.00 [0.003] 1.00-1.01 RN total hours per week 1.00 [0.004] 1.00-1.01 Patient characteristics Proportion of residents 1.00 [0.004] 1.00-1.02 age
85 years Proportion of residents who are 1.00 [0.003] 1.00-1.01 white Organizational commitment to preparedness Has a written influenza pandemic preparedness plan (reference, no) Yes, in progress 3.15y [0.84] 1.87-5.31 Yes, completed 1.94y [0.33] 1.38-2.72 Sample size: 2,274 (unweighted), 30,806 (weighted) *Significant at P < .01 level. Significant at P < .001 level.

y

nursing aide hours per week, certification of director and the presence of a written influenza pandemic preparedness plan. Specifically, compared with facilities with 4-10 beds, larger facilities were generally less likely to report a high employee influenza vaccination rate. Facilities serving residents with developmental disabilities (OR, 1.29; P < .05), those with a director with a certificate in the management of facilities for the elderly (OR, 1.60; P < .001), and those with a completed written plan for influenza preparedness (OR, 1.30; P < .05) were more likely to report a high employee influenza vaccination rate. The use of more nursing aide hours was negatively associated with the likelihood of reporting a high employee influenza vaccination rate (OR, 0.998; P < .001), although the effect size was very small. DISCUSSION The aim of this study was to identify the organizational correlates of the implementation of at least 1 influenza-related employee vaccination policy/program and to evaluate the effect of employee influenza vaccination policies on influenza vaccination uptake rates among HCWs in residential care facilities. This study is timely given the recent increasing focus on pandemic preparedness in health care facilities. We found that chain ownership, facility size, director’s educational credentials, and presence of a written influenza pandemic preparedness plan were associated with having at least 1 influenza-related employee vaccination policy/program in place in a residential care facility. In addition, our results also indicate that recommending vaccination to employees, providing vaccination on site, providing vaccinations to employees at no cost, incentivizing staff, and requiring vaccination (or contraindication) as a condition of

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employment may help residential care facilities achieve a high employee influenza vaccination rate. Similar to concerns noted in another study,35 we found that smaller facilities were less likely to have policies in place for employee vaccination. Compared with larger organizations, smaller residential care facilities may have limited resources to devote to the implementation and enforcement of vaccination policies. On the other hand, despite a lack of formal vaccination policies, smaller facilities still may be able to informally, and perhaps more effectively (owing to their size), encourage vaccination among their employees. In fact, the findings from the present study suggest that smaller facilities were more likely than large organizations to achieve high vaccination uptake among their employees. Further research is needed to identify barriers to the adoption of formal vaccination policies in smaller residential care facilities. The educational attainment of the facility director was also found to be associated with having at least 1 influenzarelated employee vaccination policy/program, suggesting that the managers’ educational and professional backgrounds influence their management practices. Accordingly, facilities with managers who were certified in the management of facilities focused on caring for the elderly were also more likely to report a high vaccination rate, further underscoring the importance of management in ensuring the successful implementation of influenza vaccination policies. In addition to the characteristics of the director, we also found the presence of an influenza pandemic plan to be positively associated with having at least 1 influenza-related employee vaccination policy/program in place, as well as with achieving a high employee influenza vaccination rate. This finding suggests that the written influenza preparedness plans in residential care organizations may delineate employee vaccination policies. Organizations committed to emergency preparedness may be more likely to encourage their staff and residents to receive appropriate vaccinations. Numerous studies have identified individual-level predictors of vaccination uptake among HCWs. These studies found that older age, race, health insurance coverage, previous vaccination, knowledge of the vaccine’s usefulness, and perceived level of risk and concern for patients were associated with the likelihood of a HCW being vaccinated.6,36-38 This study adopted an organizational perspective and sought to identify the organizational factors influencing employee influenza vaccination uptake rates. Of primary interest was identifying the policies that were most effective in improving influenza vaccination rates among HCWs in residential care facilities. Our results indicate that residential care facilities may improve their employee vaccination rates by encouraging vaccination, removing cost barriers to vaccination, and making vaccination more accessible to staff. Not surprisingly, our findings also suggest that mandating vaccination in residential care facilities might be one of the best ways to achieve maximal vaccination coverage. However, many have raised concerns about such mandates, noting that it is coercive and may have a negative impact on employer-employee relations.21,39 Our results suggest that aside from mandates, there are other successful alternative policies that can be adopted by residential care facilities, including providing free vaccinations for staff. In general, the findings from this study echo the findings from studies conducted in other health care settings.7,18,19,40 Despite its significant implications for management and practice, this study has several limitations that should be noted. First, the study was limited by the constraints set by the data used, and important potential confounding variables might not have been examined owing to data limitations. For example, the study was unable to control for individual HCW factors that might influence their decision to get vaccinated, because this information was not available from the NSRCF. Second, the study was of a cross-sectional

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Table 3 Proportion of facilities adopting various vaccination policies stratified by employee influenza vaccination uptake rates Proportion of staff vaccinated for influenza in past year, % Variable

None

1-60

61-80

81-99

100

All facilities

Sample size, n Facility recommends vaccination to staff, % Vaccinations are offered on site, % Vaccinations are offered for free, % Vaccinations are offered at a reduced cost, % Staff incentives provided for vaccinations, % Furlough or patient restriction policy for employees developing flu-like illness, % Proof of vaccination (or contraindication) required as a condition of employment, %

173 37.6 15.0 15.6 3.5 1.2 5.2 3.5

839 68.7 63.4 53.5 11.7 4.4 16.3 7.3

300 77.3 75.3 69.0 7.3 7.0 22.0 12.7

429 78.3 80.7 76.9 8.2 11.0 26.3 13.1

554 68.2 50.7 50.2 6.3 3.8 15.5 15.9

2,295 69.2 61.5 56.3 8.5 5.6 17.9 10.9

Table 4 Logistic regression: effects of employee vaccination policies on employee influenza vaccination rates High (81%-100%) proportion of staff vaccinated for influenza last year (reference, 0-80%) OR [SE]

95% CI

Independent variables: policies Facility recommends vaccination 1.58* [0.19] 1.25-2.00 to staff Vaccinations offered on site 1.46y [0.21] 1.10-1.93 Vaccinations offered for free 1.76* [0.24] 1.34-2.30 Vaccinations offered at reduced 1.01 [0.22] 0.66-1.54 cost z Staff incentives provided for 1.53 [0.32] 1.00-2.31 vaccinations 1.02 [0.14] 0.78-1.34 Furlough or patient restriction policy for employees developing flu-like illness 1.93* [0.33] 1.38-2.71 Proof of vaccination (or contraindication) required as a condition of work or employment Covariates Facility size: reference, small (4-10 beds) Medium (11-25 beds) 0.67y [0.09] 0.52-0.88 Large (26-100 beds) 0.42* [0.71] 0.31-0.59 Extra large (>100 beds) 0.53z [0.13] 0.32-0.87 1.29z [0.14] Provides services to at least 1 1.04-1.59 person with developmental disabilities 1.60* [0.22] 1.23-2.09 Director has a certificate or license related to managing facilities for older people Personal care aide total hours per 0.998* [0.0003] 0.998-0.999 week Has a written influenza pandemic preparedness plan: reference, no Yes, in progress 0.99 [0.17] 0.71-1.38 Yes, completed 1.30z [0.17] 1.01-1.67 Sample size: 2,275 (unweighted), 30,854 (weighted) Logistic regression also controlled for chain ownership, provision of respite care, and number of total LPN/LVN and RN hours. These were not statistically significant in the final model. *Significant at the P < .001 level. y Significant at the P < .01 level. z Significant at the P < .05 level.

design and thus cannot establish causality. Third, because the study was limited to residential care facilities, the findings might not be generalizable to other health care organizations. However, as noted earlier, our findings are consistent with other studies from other health care organizations. Moreover, 20 US states have laws mandating health care employers to develop and implement vaccination policies for their staff41; however, because the publicuse file of the NSRCF does not identify the states within which facilities were located, we were unable to account for this potential state effect. Finally, data from the NSRCF relies on self-reports from directors or designated staff members, as such some of the

information obtained may be subject to error; reports of employee influenza vaccination rates in some facilities, for example, may be inflated. Nevertheless, this study is significant because it is the first study to use a nationally representative sample to examine the adoption and impact of vaccination policies in residential care facilities. The study also sheds light on the extent of use of influenza vaccination policies in residential care facilities. Given the representativeness and high response rate of the NSRCF, the findings from this study can be generalized to all residential care facilities in the United States. CONCLUSION Residential care facilities are particularly important to the delivery of long-term care and the role of these facilities in health care provision is becoming increasingly critical as the US population ages. Previous studies have highlighted concerns about the lack of capacity in residential care facilities for infection control42 and pandemic preparedness.43,44 Encouraging employee influenza vaccination is one way to reduce nosocomial transmittal of the disease. Given the importance of residential care facilities in the provision of elderly care, coupled with the increased vulnerability of the elderly to influenza, more attention should be paid to HCW vaccination in residential care facilities. Facilities promoting vaccination and achieving high vaccination rates will benefit from having healthier residents and will also attain higher employee productivity resulting from decreased employee absenteeism. The study highlights the importance of managerial influence in promoting the adoption of vaccination policies and ensuring the attainment of high employee vaccination uptake. Managers therefore need to be educated on the importance of employee vaccination for them to effectively encourage their employees to get vaccinated. Residential care facilities can improve vaccination rates among employees by mandating vaccination, providing education on the importance of vaccination, providing the vaccines for free, providing incentives to staff and vaccinating at an accessible location (onsite). Providing vaccines at a reduced cost and having a patient restriction policy for sick employees might be ineffective in improving vaccination rates for influenza in residential care facilities. Future studies can expand on this work by simultaneously evaluating the effects of individual-level, organizational, and market factors on the HCW vaccination uptake rates and exploring in greater detail the most effective ways to use managers to promote and facilitate employee influenza vaccination. References 1. Shefer A, Briss P, Rodewald L, Bernier R, Strikas R, Yusuf H, et al. Improving immunization coverage rates: an evidence-based review of the literature. Epidemiol Rev 1999;21:96-142. 2. Thompson W, Shay D, Weintraub E, Brammer L, Bridges C, Cox N, et al. Influenza-associated hospitalizations in the United States. JAMA 2004;292:1333-40. 3. Fiore A, Uyeki T, Broder K, Finelli L, Euler G, Singleton JA, et al. Prevention and control of influenza with vaccines: recommendations of the Advisory

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