CARE OF THE OLDER PERSON
Maximising influenza vaccination uptake among older people Savita Bakhshi, Alison E. While
Savita Bakhshi, Research Associate, Florence Nightingale Faculty of Nursing and Midwifery, King’s College London; Alison E. While, Emeritus Professor, Florence Nightingale Faculty of Nursing and Midwifery, King’s College London Email: [email protected]
ABSTRACT
Older adults aged 65 years and over are particularly vulnerable to seasonal influenza as their immune system is weaker than that of younger adults. The influenza vaccination helps to reduce influenza severity and the incidence of complications, but a range of factors can affect uptake among older people. These factors can be categorised as follows: the system of vaccination; influenza vaccination mistrust and fear of side-effects; health beliefs and behaviours; and other factors. Various interventions to maximise influenza vaccination uptake among older people in the community have been identified, including: interventions to increase community demand, enhance access and improve influenza vaccination among community nurses, as well as provider or system-based interventions and societal interventions. Community nurses have been found to have a positive influence on influenza vaccination uptake and should continue to promote the benefits of influenza vaccination to their patients who are ‘persistent decliners’.
KEY WORDS
w Influenza w Vaccination w Older people w Health beliefs w Uptake
474
illness among older adults compared with younger adults, it helps to reduce disease severity and the incidence of complications (Monto et al, 2009; Thomas et al, 2010a; World Health Organization, 2014). Staff vaccination programmes can also help to reduce the transmission of the virus to other staff and patients, leading to lower levels of staff illness and absenteeism (Anikeeva et al, 2009) as well as being beneficial in terms of virus transmission to vulnerable patients.
Influenza vaccination uptake among older people Older adults aged 65 years and over are particularly vulnerable to influenza as their immune system is less effective (Monto et al, 2009). The presence of comorbidities in this age group also increases the risks of severe illnesses, a decline in physical functioning, and influenza-related deaths. Provisional data from Public Health England show that seasonal influenza vaccination uptake among GP patients from 1 September 2013 to 31 January 2014 for patients aged 65 years and older was 73.2%, down slightly from 73.4% during the same period the previous year (Public Health England, 2014a).
Influenza vaccination uptake among community nurses It is imperative that primary care health professionals (including community nurses delivering care to older adults) are vaccinated every year, as they may transmit influenza to their patients, particularly if they continue to work when infected (Fiore et al, 2008;Thomas et al, 2010a). Furthermore, it seems that not all infected individuals display the obvious symptoms of influenza, which makes the universal vaccination of health professionals the desired goal for all health-care service providers. Past research has shown that higher influenza vaccination rates among health professionals are associated with lower mortality rates among elderly patients (Potter et al, 1997; Carman et al, 2000). However, other research remains inconclusive owing to methodological issues relating to studies (Thomas et al, 2010a). Provisional data from staff in all types of NHS service settings shows that seasonal influenza vaccination uptake among frontline health professionals from
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S
easonal influenza is an acute viral infection that spreads from person to person and is characterised by symptoms such as a high fever, headaches, muscle and joint pain, a cough, sore throat and runny nose. Most people recover from this infection within a week. However, some individuals display no or very minor symptoms but can still spread the virus among their contacts. The prevalence of influenza is estimated at 5–10% in adults and 20–30% in children worldwide, causing between 3 million and 5 million cases of severe illness and approximately 250 000 to 500 000 deaths annually (World Health Organization, 2014). Seasonal influenza can lead to severe illness and increased mortality in high-risk populations such as children under 2 years of age, pregnant women, older people (i.e. those 65 years or older) and people with chronic medical conditions (World Health Organization, 2014). An annual influenza vaccination can provide safe and effective protection against the onset of influenza, particularly for high-risk groups and those who are regularly exposed to these groups, such as health professionals (World Health Organization, 2014). While the influenza vaccination may be less effective in preventing
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CARE OF THE OLDER PERSON Table 1. Influenza vaccination uptake: facilitators and barriers Theme System of vaccination
Facilitators
w Recommendations by a health professional w Recommendations by family and friends w Exposure to information campaigns
Influenza vaccination effectiveness and sideeffects
w Perceived effectiveness and safety of the influenza vaccination w Fear of injections/needles w Perceived side-effects from the influenza vaccination w Actual side-effects from past vaccinations w Perceived benefits of influenza vaccination
Health beliefs and behaviours
w Perceived likelihood of catching influenza w Perceived likelihood of passing influenza onto others w Perceived severity of influenza vaccination w Perceived health status w Knowledge and understanding of the influenza vaccination w Influenza history of vaccinations
Other
w Demographics w Work-related factors w Personality factors w Financial factors w Lifestyle factors
follows (While et al, 2005; Blank et al, 2008; Kwong et al, 2009; Wheelock et al, 2013): w System of vaccination w Influenza vaccination mistrust and fear of side-effects w Health beliefs and behaviours w Other factors. These facilitators and barriers can be found in Table 1.
Individual factors Research has shown that recommendations by health professionals can be one of the strongest predictors of influenza vaccination uptake (Mangtani et al, 2006; Evans et al, 2007). These recommendations may be enhanced by exposure to official and commercial information campaigns through the media and other reliable sources (Rubin et al, 2010). Older people’s knowledge and beliefs about the influenza vaccination can have a significant effect on uptake (Evans et al, 2007). An individual’s perceived immunity and resistance to influenza (i.e. the likelihood of coming into contact with someone with influenza, becoming infected and then passing it onto others) also have significant associations with influenza vaccination uptake (Mangtani et al, 2006; Evans et al, 2007; Blank et al, 2008; Prior et al, 2011). In addition, research has shown that those who have had the influenza vaccination previously are more likely to have it in the future (Xakellis, 2005; Mangtani et al, 2006; Nagata et al, 2013). Furthermore, an individual’s belief that their family and friends would like them to be vaccinated, and their past positive and negative experiences of the influenza vaccination, can also have a significant effect on vaccination uptake (Burns et al, 2005; Prior et al, 2011).
1 September 2013 to 31 January 2014 was 54.8%—an increase of 8.9% compared with the same period in the previous year (Public Health England, 2014b). Additionally, community nurses may translate their own attitudes, beliefs and behaviours into their professional practices with older patients (Brunton et al, 2005; O’Reilly et al, 2005; Chalmers, 2006; Zhang et al, 2012). For example, a qualitative study found that nurses who had been vaccinated were more enthusiastic and proactive about promoting and educating vaccination with their patients compared with unvaccinated nurses (Willis and Wortley, 2007). Similarly, Zhang et al (2012) found that vaccinated nurses were more likely to promote the influenza vaccination to their patients compared with unvaccinated nurses.
Facilitators of and barriers to influenza vaccination uptake among older people A range of factors can affect influenza vaccination uptake among older people (Blank et al, 2009; European Centre for Disease Prevention and Control, 2013; Nagata et al, 2013). These facilitators and barriers can be classified as
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The decision to get vaccinated may be largely dependent upon an individual’s perception of the effectiveness and safety of the influenza vaccination. This may include the level of vaccination testing, the perceived benefits of the influenza vaccination (i.e. prevention of influenza, fewer and less severe symptoms and fewer medical consultations), and potential and actual side-effects from past vaccinations (Mangtani et al, 2006; Evans et al, 2007; Kwong et al, 2009). Other factors relating to demographics, previous or current work, personality, finance and lifestyle have also been found to be associated with influenza vaccination uptake among older people, although the findings have been inconclusive (Crawford et al, 2011). A range of personal and professional factors may influence influenza vaccination uptake among community nurses (Chalmers, 2006). Research has found a strong relationship between nurses’ knowledge of influenza/vaccination and their vaccination status (O’Reilly et al, 2005; Zhang et al, 2012). Similarly, vaccinated nurses hold significantly different attitudes toward influenza and influenza vaccination than those who are not vaccinated (Chalmers, 2006). Concerns about the influenza vaccination’s side-effects and safety, misconceptions, a lack of knowledge and perception of influenza as a minor illness are potential barriers
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Getting vaccinated
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TOPIC HEADER CARE OF THE OLDER PERSON to vaccination uptake among nurses (Hollmeyer et al, 2009; Thomas et al, 2010a; Zhang et al, 2012). In addition, health professionals who do not get vaccinated hold a low perceived risk for themselves and their patients, and have concerns about the efficacy of the influenza vaccination and its side-effects (Thomas et al, 2010a).
Approaches to maximising influenza vaccination uptake Various interventions for maximising influenza vaccination uptake among older people in the community have been identified (While et al, 2005; Thomas et al, 2010b). These interventions can be categorised as (Thomas et al, 2010b; European Centre for Disease Prevention and Control, 2013): w Interventions to increase community demand w Interventions to enhance access w Provider or system-based interventions w Societal interventions w Interventions to improve influenza vaccination among community nurses. Each of these factors will be addressed directly in the following sections.
Interventions to increase community demand Influenza vaccination uptake among older people can be increased by providing motivators and reminders to get vaccinated. Reminders that can be sent to a patient’s home can include personalised postcards, letters, leaflets, text messages and telephone campaigns conducted on a local and/or national level (Burns et al, 2005; Evans et al, 2007; Dexter et al, 2012; European Centre for Disease Prevention and Control, 2013; Herrett et al, 2014). This information should focus on providing detailed information on the benefits of the vaccination and ways of overcoming some, if not all, of the barriers to influenza vaccination uptake (i.e. perceived effectiveness, safety and side-effects) (Burns et al, 2005).
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Interventions to enhance access Research has identified factors such as the availability and accessibility of influenza vaccination as potential barriers to the uptake of the vaccination in older people (Mangtani et al, 2006). For example, those who use medical services more frequently are more likely to get an influenza vaccination (European Centre for Disease Prevention and Control, 2013). A lack of transportation and the presence of comorbidities and/or limited physical functioning may prevent older people from being able to receive the vaccination. For this reason, home visits should be provided for those who are unable to attend GP surgeries or health centres, as this enables accessibility to vaccination (European Centre for Disease Prevention and Control, 2013). Information relating to the provision of free-of-cost influenza vaccinations for people who are 65 years and over, in long-stay residential care, and acting as carers should also be widely disseminated among older people together
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with easy accessibility to vaccination to encourage uptake in a timely manner.
Provider or system-based interventions Interventions for patients who are able to attend GP surgeries or health centres can also be provided in the form of information using system-based interventions. For example, local and NHS information leaflets about influenza and the benefits of being vaccinated should provide easy-tounderstand messages that can be passed on to others who may also be high-risk patients. Reminders to patients to make an appointment to be vaccinated and how to do this can also be displayed on posters in waiting rooms. In addition, a short note about vaccination programmes should be provided on repeat prescriptions, and older people and other vulnerable patients attending GP surgeries, health centres and community facilities could be reminded to be vaccinated by receptionists, practice managers and health professionals (Evans et al, 2007). Research has also suggested that financial targets can help to incentivise general practices to encourage influenza vaccination uptake in their patients (Dexter et al, 2012).
Societal interventions Interventions to increase influenza vaccination uptake in older patients could also be implemented through Government policies and outreach programmes. One example may include paying health professionals to achieve specific vaccination targets especially focusing on those patients who are ‘persistent decliners’ and those who have comorbidities, which puts them at a higher risk of severe illnesses, a decline in physical functioning, and influenzarelated deaths (Zhang et al, 2012).
Interventions to improve influenza vaccination among community nurses Recent research indicates that interventions can help to improve influenza vaccination among community nurses, which can in turn help to increase influenza vaccination uptake among older people (European Centre for Disease Prevention and Control, 2013). A recent systematic review has shown that this may include single and combined interventions using the following components: education or promotion of prophylaxis uptake; improved access to vaccination; legislation or regulation; measurement or feedback; and relevant role models (Lam et al, 2010). However, compulsory seasonal influenza vaccination for health professionals raises a series of ethical issues. While health professionals have a professional and ethical obligation to protect their patients’ health, it challenges their personal autonomy and freedom of choice (van Delden et al, 2008; Stewart, 2009). It is unlikely that vaccination will become compulsory for health professionals in the UK, although it could be argued that health professionals have a moral duty to ensure that they are not vectors of infections for their patients and should minimise potential causes of absenteeism from their workplace (While, 2014). The current approach to the vaccination of community nurses and
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CARE OF THE OLDER PERSON
Implications for clinical practice Maximising influenza vaccination uptake among older people and other vulnerable patients is a public health priority because it both reduces the demands upon limited healthcare resources and prevents an avoidable illness and the negative consequences arising from an episode of influenza. It appears that individuals may hold various misconceptions about influenza and influenza vaccination, which can in turn affect their vaccination behaviour (Evans et al, 2007). Such misconceptions may be rectified through improved patient education and health promotion programmes for health professionals (Hollmeyer et al, 2009). For example, information relating to the influenza vaccination should be readily available and accessible to patients in high-risk groups. Older people and other vulnerable patients should also be provided with ample opportunity to discuss their concerns with their health professionals to enable them to make informed choices. Effective vaccination programmes also need to target the needs of older people, and those who are less mobile (While et al, 2005). For example, the timing of vaccination campaigns is an important consideration, as individuals and health professionals need adequate time and resources to process information, make decisions and make preparations for effective vaccination programmes to enable as many as possible to be vaccinated in a timely manner prior to the annual seasonal influenza peak.
Community nursing input The beliefs and behaviours of community nurses also need consideration. Similar to patients, health professionals may also need detailed information about the vaccination, which may help to correct any misconceptions about their perceived immunity against influenza and its transmission, and concerns about the perceived effectiveness and safety of the influenza vaccination. Improved knowledge about influenza and its transmission together with the effectiveness and safety of the vaccine may help to overcome some, if not all, of the barriers to influenza vaccination uptake, thereby helping to translate their own attitudes, beliefs and behaviours into their professional practices with their patients (Willis and Wortley, 2007; Dexter et al, 2012). However, inconclusive findings indicate that only vaccinating health professionals may not prevent influenza in older patients (Thomas et al, 2010a). Other preventative health behaviours such as washing hands thoroughly, wearing masks, and not attending work with flu-like symptoms may help to reduce the transmission of the virus to other staff and patients (Thomas et al, 2010a).
Conclusion It is clear from the research that a range of factors can influence influenza vaccination uptake among older people and they need careful consideration when interventions are being developed to promote increased uptake. Community
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nurses have been found to have a positive influence upon influenza vaccination uptake and they should continue to promote vaccination uptake to their patients who are ‘persistent decliners’ through approaches discussed in this article. There is limited evidence indicating that employing case managers within interdisciplinary teams may help to facilitate higher uptake of influenza vaccination in older people (Onder et al, 2008; Dexter et al, 2012; European Centre for Disease Prevention and Control, 2013) and localities with lower uptake rates may wish to explore whether such an approach is helpful. These case managers need to be aware of and understand the various facilitators and barriers to influenza vaccination uptake in older people as well as any cultural beliefs and practices that may influence beliefs and prophylactic behaviours. Achieving high seasonal influenza vaccination rates among older people and other vulnerable groups will have benefits for the individuals themselves as well as health services through avoidable hospital admissions due to severe seasonable influenza and its complications. BJCN Accepted for publication: 24 June 2014 The authors declare that there is no conflict of interest
Anikeeva O, Braunack-Mayer A, Rogers W (2009) Requiring influenza vaccination for health care workers. Am J Pub Health 99(1): 24–9. doi: 10.2105/ AJPH.2008.136440 Blank P, Schwenkglenks M, Szucs T (2008) Influenza vaccination coverage rates in five European countries during season 2006/07 and trends over six consecutive seasons. BMC Pub Health 8(1): 272. doi: 10.1186/1471-2458-8-272 Blank PR, Schwenkglenks M, Szucs TD (2009) Disparities in influenza vaccination coverage rates by target group in five European countries: trends over seven consecutive seasons. Infection 37(5): 390–400. doi: 10.1007/s15010-009-8467-y Brunton C, Weir R, Jennings L (2005) Knowledge and attitudes about influenza vaccination amongst general practitioners, practice nurses, and people aged 65 and over. N Z Med J 118(1214): U1434 Burns VE, Ring C, Carroll D (2005) Factors influencing influenza vaccination uptake in an elderly, community-based sample. Vaccine 23(27): 3604–8 Carman WF, Elder AG, Wallace LA et al (2000) Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial. Lancet 355(9198): 93–7 Chalmers C (2006) Understanding healthcare worker uptake of influenza vaccination: a survey. J Infect Control 7(2): 12–17 Crawford VLS, O’Hanlon A, McGee H (2011) The effect of patient characteristics upon uptake of the influenza vaccination: a study comparing community-based older adults in two healthcare systems. Age Ageing 40(1): 35–41. doi: 10.1093/ ageing/afq152 Dexter LJ, Teare MD, Dexter M, Siriwardena AN, Read RC (2012) Strategies to increase influenza vaccination rates: outcomes of a nationwide cross-sectional survey of UK general practice. BMJ Open 2(3): e000851. doi:10.1136/bmjopen-2011-000851 European Centre for Disease Prevention and Control (2013) Review of the Scientific Literature on Drivers and Barriers of Seasonal Influenza Vaccination Coverage in the EU/ EEA. Stockholm: ECDC. http://tinyurl.com/k8fm98o (accessed 13 May 2014) Evans MR, Prout H, Prior L, Tapper-Jones LM, Butler CC (2007) A qualitative study of lay beliefs about influenza immunisation in older people. Br J Gen Pract 57(538): 352–8 Fiore AE, Shay DK, Broder K et al (2008) Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008. Morbidity and Mortality Weekly Report 57(RR-7): 1–60. http://tinyurl.com/ c9tkcl (accessed 2 September 2014) Herrett E, van Staa T, Free C, Smeeth L (2014) Text messaging reminders for influenza vaccine in primary care: protocol for a cluster randomised controlled trial (TXT4FLUJAB). BMJ Open 4(5): e004633. doi:10.1136/bmjopen-2013-004633 Hollmeyer HG, Hayden F, Poland G, Buchholz U (2009) Influenza vaccination of health care workers in hospitals: a review of studies on attitudes and predictors. Vaccine 27(30): 3935–44. doi: 10.1016/j.vaccine.2009.03.056
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other health professionals may need further consideration if vaccination levels are to be improved to meet desired levels of immunity.
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TOPIC HEADER CARE OF THE OLDER PERSON enza vaccination rates of those 60 years and older in the community. Cochrane Database Syst Rev 2010(9): CD005188. doi: 10.1002/14651858.CD005188. pub2 van Delden JJ, Ashcroft R, Dawson A, Marckmann G, Upshur R, Verweij MF (2008) The ethics of mandatory vaccination against influenza for health care workers. Vaccine 26(44): 5562–6. doi: 10.1016/j.vaccine.2008.08.002 Wheelock A, Thomson A, Sevdalis N (2013) Social and psychological factors underlying adult vaccination behavior: lessons from seasonal influenza vaccination in the US and the UK. Expert Rev Vaccines 12(8): 893–901. doi: 10.1586/14760584.2013.814841 While AE (2014) Are nurses fit for their public health role? Int J Nurs Stud. In press. http://tinyurl.com/p2xl5g5 (accessed 15 May 2014) While AE, George C, Murgatroyd B (2005) Promoting influenza vaccination in older people: rationale and reality. Br J Community Nurs 10(9): 427–30 Willis BC,Wortley P (2007) Nurses’ attitudes and beliefs about influenza and the influenza vaccine: a summary of focus groups in Alabama and Michigan. Am J Infect Control 35(1): 20–4 World Health Organization (2014) Influenza (seasonal). Fact sheet no. 211. http://tinyurl.com/cmj8ty (accessed 11 April 2014) Xakellis GC (2005) Predictors of influenza immunization in persons over age 65. J Am Board Family Pract 18(5): 426–33
Kwong EW, Lam IO, Chan TM (2009) What factors affect influenza vaccine uptake among community-dwelling older Chinese people in Hong Kong general outpatient clinics? J Clin Nurs 18(7): 960–71. doi: 10.1111/j.13652702.2008.02548.x Lam P-P, Chambers LW, MacDougall DMP, McCarthy AE (2010) Seasonal influenza vaccination campaigns for health care personnel: systematic review. CMAJ 182(12): E542–8. doi: 10.1503/cmaj.091304 Mangtani P, Breeze E, Stirling S, Hanciles S, Kovats S, Fletcher A (2006) Crosssectional survey of older peoples’ views related to influenza vaccine uptake. BMC Public Health 6(1): 249 Monto AS, Ansaldi F, Aspinall R et al (2009) Influenza control in the 21st century: optimizing protection of older adults. Vaccine 27(37): 5043–53 Nagata J, Hernandez-Ramos I, Kurup A, Albrecht D, Vivas-Torrealba C, FrancoParedes C (2013) Social determinants of health and seasonal influenza vaccination in adults ≥65 years: a systematic review of qualitative and quantitative data. BMC Public Health 13(1): 388. doi:10.1186/1471-2458-13-388 O’Reilly FW, Cran GW, Stevens AB (2005) Factors affecting influenza vaccine uptake among health care workers. Occup Med 55(6): 474–9 Onder G, Liperoti R, Bernabei R, Landi F (2008) Case management, preventive strategies, and caregiver attitudes among older adults in home care: results of the ADHOC study. J Am Med Dir Assoc 9(5): 337–41. doi: 10.1016/j. jamda.2008.02.002 Potter J, Stott DJ, Roberts MA et al (1997) Influenza vaccination of health care workers in long-term-care hospitals reduces the mortality of elderly patients. J Infect Dis 175(1): 1–6 Prior L, Evans MR, Prout H (2011) Talking about colds and flu: the lay diagnosis of two common illnesses among older British people. Soc Sci Med 73(6): 922–8. doi: 10.1016/j.socscimed.2010.09.054 Public Health England (2014a) Seasonal flu vaccine uptake in GP patients 1 September 2013 to 31 January 2014. Statistics. http://tinyurl.com/ozc23zt (accessed 14 April 2014) Public Health England (2014b) Seasonal flu vaccine uptake in healthcare workers 1 September 2013 to 31 January 2014. Statistics. http://tinyurl.com/ pz4ovhj (accessed 14 April 2014) Rubin GJ, Potts HW, Michie S (2010) The impact of communications about swine flu (influenza A H1N1v) on public responses to the outbreak: results from 36 national telephone surveys in the UK. Health Technol Assess 14(34): 183–266. doi: 10.3310/hta14340-03 Stewart AM (2009) Mandatory vaccination of health care workers. N Eng J Med 361(21): 2015–17 Thomas RE, Jefferson T, Lasserson TJ (2010a) Influenza vaccination for healthcare workers who work with the elderly. Cochrane Database Syst Rev 2010(2): CD005187. doi: 10.1002/14651858.CD005187.pub3 Thomas RE, Russell M, Lorenzetti D (2010b) Interventions to increase influ-
KEY POINTS
w Older adults aged 65 years and over are particularly vulnerable to influenza
w Influenza vaccination uptake can be influenced by the system of vaccination, vaccination mistrust and fear of side-effects, as well as health beliefs and behaviours w Interventions to increase community demand and access and provider, system-based and societal interventions can help maximise influenza vaccination uptake among older people w Improved knowledge on ways of overcoming barriers to influenza vaccination uptake may help to translate community nurses’ attitudes, beliefs and behaviours into their professional practices with their patients
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Maximising influenza vaccination uptake among older people Savita Bakhshi, Alison E. While
Savita Bakhshi, Research Associate, Florence Nightingale Faculty of Nursing and Midwifery, King’s College London; Alison E. While, Emeritus Professor, Florence Nightingale Faculty of Nursing and Midwifery, King’s College London Email: [email protected]
ABSTRACT
Older adults aged 65 years and over are particularly vulnerable to seasonal influenza as their immune system is weaker than that of younger adults. The influenza vaccination helps to reduce influenza severity and the incidence of complications, but a range of factors can affect uptake among older people. These factors can be categorised as follows: the system of vaccination; influenza vaccination mistrust and fear of side-effects; health beliefs and behaviours; and other factors. Various interventions to maximise influenza vaccination uptake among older people in the community have been identified, including: interventions to increase community demand, enhance access and improve influenza vaccination among community nurses, as well as provider or system-based interventions and societal interventions. Community nurses have been found to have a positive influence on influenza vaccination uptake and should continue to promote the benefits of influenza vaccination to their patients who are ‘persistent decliners’.
KEY WORDS
w Influenza w Vaccination w Older people w Health beliefs w Uptake
474
illness among older adults compared with younger adults, it helps to reduce disease severity and the incidence of complications (Monto et al, 2009; Thomas et al, 2010a; World Health Organization, 2014). Staff vaccination programmes can also help to reduce the transmission of the virus to other staff and patients, leading to lower levels of staff illness and absenteeism (Anikeeva et al, 2009) as well as being beneficial in terms of virus transmission to vulnerable patients.
Influenza vaccination uptake among older people Older adults aged 65 years and over are particularly vulnerable to influenza as their immune system is less effective (Monto et al, 2009). The presence of comorbidities in this age group also increases the risks of severe illnesses, a decline in physical functioning, and influenza-related deaths. Provisional data from Public Health England show that seasonal influenza vaccination uptake among GP patients from 1 September 2013 to 31 January 2014 for patients aged 65 years and older was 73.2%, down slightly from 73.4% during the same period the previous year (Public Health England, 2014a).
Influenza vaccination uptake among community nurses It is imperative that primary care health professionals (including community nurses delivering care to older adults) are vaccinated every year, as they may transmit influenza to their patients, particularly if they continue to work when infected (Fiore et al, 2008;Thomas et al, 2010a). Furthermore, it seems that not all infected individuals display the obvious symptoms of influenza, which makes the universal vaccination of health professionals the desired goal for all health-care service providers. Past research has shown that higher influenza vaccination rates among health professionals are associated with lower mortality rates among elderly patients (Potter et al, 1997; Carman et al, 2000). However, other research remains inconclusive owing to methodological issues relating to studies (Thomas et al, 2010a). Provisional data from staff in all types of NHS service settings shows that seasonal influenza vaccination uptake among frontline health professionals from
© 2014 MA Healthcare Ltd
S
easonal influenza is an acute viral infection that spreads from person to person and is characterised by symptoms such as a high fever, headaches, muscle and joint pain, a cough, sore throat and runny nose. Most people recover from this infection within a week. However, some individuals display no or very minor symptoms but can still spread the virus among their contacts. The prevalence of influenza is estimated at 5–10% in adults and 20–30% in children worldwide, causing between 3 million and 5 million cases of severe illness and approximately 250 000 to 500 000 deaths annually (World Health Organization, 2014). Seasonal influenza can lead to severe illness and increased mortality in high-risk populations such as children under 2 years of age, pregnant women, older people (i.e. those 65 years or older) and people with chronic medical conditions (World Health Organization, 2014). An annual influenza vaccination can provide safe and effective protection against the onset of influenza, particularly for high-risk groups and those who are regularly exposed to these groups, such as health professionals (World Health Organization, 2014). While the influenza vaccination may be less effective in preventing
British Journal of Community Nursing October 2014 Vol 19, No 10
sh Journal of Community Nursing.Downloaded from magonlinelibrary.com by 193.061.135.080 on February 5, 2015. For personal use only. No other uses without permission. . All rights rese
CARE OF THE OLDER PERSON Table 1. Influenza vaccination uptake: facilitators and barriers Theme System of vaccination
Facilitators
w Recommendations by a health professional w Recommendations by family and friends w Exposure to information campaigns
Influenza vaccination effectiveness and sideeffects
w Perceived effectiveness and safety of the influenza vaccination w Fear of injections/needles w Perceived side-effects from the influenza vaccination w Actual side-effects from past vaccinations w Perceived benefits of influenza vaccination
Health beliefs and behaviours
w Perceived likelihood of catching influenza w Perceived likelihood of passing influenza onto others w Perceived severity of influenza vaccination w Perceived health status w Knowledge and understanding of the influenza vaccination w Influenza history of vaccinations
Other
w Demographics w Work-related factors w Personality factors w Financial factors w Lifestyle factors
follows (While et al, 2005; Blank et al, 2008; Kwong et al, 2009; Wheelock et al, 2013): w System of vaccination w Influenza vaccination mistrust and fear of side-effects w Health beliefs and behaviours w Other factors. These facilitators and barriers can be found in Table 1.
Individual factors Research has shown that recommendations by health professionals can be one of the strongest predictors of influenza vaccination uptake (Mangtani et al, 2006; Evans et al, 2007). These recommendations may be enhanced by exposure to official and commercial information campaigns through the media and other reliable sources (Rubin et al, 2010). Older people’s knowledge and beliefs about the influenza vaccination can have a significant effect on uptake (Evans et al, 2007). An individual’s perceived immunity and resistance to influenza (i.e. the likelihood of coming into contact with someone with influenza, becoming infected and then passing it onto others) also have significant associations with influenza vaccination uptake (Mangtani et al, 2006; Evans et al, 2007; Blank et al, 2008; Prior et al, 2011). In addition, research has shown that those who have had the influenza vaccination previously are more likely to have it in the future (Xakellis, 2005; Mangtani et al, 2006; Nagata et al, 2013). Furthermore, an individual’s belief that their family and friends would like them to be vaccinated, and their past positive and negative experiences of the influenza vaccination, can also have a significant effect on vaccination uptake (Burns et al, 2005; Prior et al, 2011).
1 September 2013 to 31 January 2014 was 54.8%—an increase of 8.9% compared with the same period in the previous year (Public Health England, 2014b). Additionally, community nurses may translate their own attitudes, beliefs and behaviours into their professional practices with older patients (Brunton et al, 2005; O’Reilly et al, 2005; Chalmers, 2006; Zhang et al, 2012). For example, a qualitative study found that nurses who had been vaccinated were more enthusiastic and proactive about promoting and educating vaccination with their patients compared with unvaccinated nurses (Willis and Wortley, 2007). Similarly, Zhang et al (2012) found that vaccinated nurses were more likely to promote the influenza vaccination to their patients compared with unvaccinated nurses.
Facilitators of and barriers to influenza vaccination uptake among older people A range of factors can affect influenza vaccination uptake among older people (Blank et al, 2009; European Centre for Disease Prevention and Control, 2013; Nagata et al, 2013). These facilitators and barriers can be classified as
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The decision to get vaccinated may be largely dependent upon an individual’s perception of the effectiveness and safety of the influenza vaccination. This may include the level of vaccination testing, the perceived benefits of the influenza vaccination (i.e. prevention of influenza, fewer and less severe symptoms and fewer medical consultations), and potential and actual side-effects from past vaccinations (Mangtani et al, 2006; Evans et al, 2007; Kwong et al, 2009). Other factors relating to demographics, previous or current work, personality, finance and lifestyle have also been found to be associated with influenza vaccination uptake among older people, although the findings have been inconclusive (Crawford et al, 2011). A range of personal and professional factors may influence influenza vaccination uptake among community nurses (Chalmers, 2006). Research has found a strong relationship between nurses’ knowledge of influenza/vaccination and their vaccination status (O’Reilly et al, 2005; Zhang et al, 2012). Similarly, vaccinated nurses hold significantly different attitudes toward influenza and influenza vaccination than those who are not vaccinated (Chalmers, 2006). Concerns about the influenza vaccination’s side-effects and safety, misconceptions, a lack of knowledge and perception of influenza as a minor illness are potential barriers
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Getting vaccinated
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TOPIC HEADER CARE OF THE OLDER PERSON to vaccination uptake among nurses (Hollmeyer et al, 2009; Thomas et al, 2010a; Zhang et al, 2012). In addition, health professionals who do not get vaccinated hold a low perceived risk for themselves and their patients, and have concerns about the efficacy of the influenza vaccination and its side-effects (Thomas et al, 2010a).
Approaches to maximising influenza vaccination uptake Various interventions for maximising influenza vaccination uptake among older people in the community have been identified (While et al, 2005; Thomas et al, 2010b). These interventions can be categorised as (Thomas et al, 2010b; European Centre for Disease Prevention and Control, 2013): w Interventions to increase community demand w Interventions to enhance access w Provider or system-based interventions w Societal interventions w Interventions to improve influenza vaccination among community nurses. Each of these factors will be addressed directly in the following sections.
Interventions to increase community demand Influenza vaccination uptake among older people can be increased by providing motivators and reminders to get vaccinated. Reminders that can be sent to a patient’s home can include personalised postcards, letters, leaflets, text messages and telephone campaigns conducted on a local and/or national level (Burns et al, 2005; Evans et al, 2007; Dexter et al, 2012; European Centre for Disease Prevention and Control, 2013; Herrett et al, 2014). This information should focus on providing detailed information on the benefits of the vaccination and ways of overcoming some, if not all, of the barriers to influenza vaccination uptake (i.e. perceived effectiveness, safety and side-effects) (Burns et al, 2005).
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Interventions to enhance access Research has identified factors such as the availability and accessibility of influenza vaccination as potential barriers to the uptake of the vaccination in older people (Mangtani et al, 2006). For example, those who use medical services more frequently are more likely to get an influenza vaccination (European Centre for Disease Prevention and Control, 2013). A lack of transportation and the presence of comorbidities and/or limited physical functioning may prevent older people from being able to receive the vaccination. For this reason, home visits should be provided for those who are unable to attend GP surgeries or health centres, as this enables accessibility to vaccination (European Centre for Disease Prevention and Control, 2013). Information relating to the provision of free-of-cost influenza vaccinations for people who are 65 years and over, in long-stay residential care, and acting as carers should also be widely disseminated among older people together
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with easy accessibility to vaccination to encourage uptake in a timely manner.
Provider or system-based interventions Interventions for patients who are able to attend GP surgeries or health centres can also be provided in the form of information using system-based interventions. For example, local and NHS information leaflets about influenza and the benefits of being vaccinated should provide easy-tounderstand messages that can be passed on to others who may also be high-risk patients. Reminders to patients to make an appointment to be vaccinated and how to do this can also be displayed on posters in waiting rooms. In addition, a short note about vaccination programmes should be provided on repeat prescriptions, and older people and other vulnerable patients attending GP surgeries, health centres and community facilities could be reminded to be vaccinated by receptionists, practice managers and health professionals (Evans et al, 2007). Research has also suggested that financial targets can help to incentivise general practices to encourage influenza vaccination uptake in their patients (Dexter et al, 2012).
Societal interventions Interventions to increase influenza vaccination uptake in older patients could also be implemented through Government policies and outreach programmes. One example may include paying health professionals to achieve specific vaccination targets especially focusing on those patients who are ‘persistent decliners’ and those who have comorbidities, which puts them at a higher risk of severe illnesses, a decline in physical functioning, and influenzarelated deaths (Zhang et al, 2012).
Interventions to improve influenza vaccination among community nurses Recent research indicates that interventions can help to improve influenza vaccination among community nurses, which can in turn help to increase influenza vaccination uptake among older people (European Centre for Disease Prevention and Control, 2013). A recent systematic review has shown that this may include single and combined interventions using the following components: education or promotion of prophylaxis uptake; improved access to vaccination; legislation or regulation; measurement or feedback; and relevant role models (Lam et al, 2010). However, compulsory seasonal influenza vaccination for health professionals raises a series of ethical issues. While health professionals have a professional and ethical obligation to protect their patients’ health, it challenges their personal autonomy and freedom of choice (van Delden et al, 2008; Stewart, 2009). It is unlikely that vaccination will become compulsory for health professionals in the UK, although it could be argued that health professionals have a moral duty to ensure that they are not vectors of infections for their patients and should minimise potential causes of absenteeism from their workplace (While, 2014). The current approach to the vaccination of community nurses and
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CARE OF THE OLDER PERSON
Implications for clinical practice Maximising influenza vaccination uptake among older people and other vulnerable patients is a public health priority because it both reduces the demands upon limited healthcare resources and prevents an avoidable illness and the negative consequences arising from an episode of influenza. It appears that individuals may hold various misconceptions about influenza and influenza vaccination, which can in turn affect their vaccination behaviour (Evans et al, 2007). Such misconceptions may be rectified through improved patient education and health promotion programmes for health professionals (Hollmeyer et al, 2009). For example, information relating to the influenza vaccination should be readily available and accessible to patients in high-risk groups. Older people and other vulnerable patients should also be provided with ample opportunity to discuss their concerns with their health professionals to enable them to make informed choices. Effective vaccination programmes also need to target the needs of older people, and those who are less mobile (While et al, 2005). For example, the timing of vaccination campaigns is an important consideration, as individuals and health professionals need adequate time and resources to process information, make decisions and make preparations for effective vaccination programmes to enable as many as possible to be vaccinated in a timely manner prior to the annual seasonal influenza peak.
Community nursing input The beliefs and behaviours of community nurses also need consideration. Similar to patients, health professionals may also need detailed information about the vaccination, which may help to correct any misconceptions about their perceived immunity against influenza and its transmission, and concerns about the perceived effectiveness and safety of the influenza vaccination. Improved knowledge about influenza and its transmission together with the effectiveness and safety of the vaccine may help to overcome some, if not all, of the barriers to influenza vaccination uptake, thereby helping to translate their own attitudes, beliefs and behaviours into their professional practices with their patients (Willis and Wortley, 2007; Dexter et al, 2012). However, inconclusive findings indicate that only vaccinating health professionals may not prevent influenza in older patients (Thomas et al, 2010a). Other preventative health behaviours such as washing hands thoroughly, wearing masks, and not attending work with flu-like symptoms may help to reduce the transmission of the virus to other staff and patients (Thomas et al, 2010a).
Conclusion It is clear from the research that a range of factors can influence influenza vaccination uptake among older people and they need careful consideration when interventions are being developed to promote increased uptake. Community
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nurses have been found to have a positive influence upon influenza vaccination uptake and they should continue to promote vaccination uptake to their patients who are ‘persistent decliners’ through approaches discussed in this article. There is limited evidence indicating that employing case managers within interdisciplinary teams may help to facilitate higher uptake of influenza vaccination in older people (Onder et al, 2008; Dexter et al, 2012; European Centre for Disease Prevention and Control, 2013) and localities with lower uptake rates may wish to explore whether such an approach is helpful. These case managers need to be aware of and understand the various facilitators and barriers to influenza vaccination uptake in older people as well as any cultural beliefs and practices that may influence beliefs and prophylactic behaviours. Achieving high seasonal influenza vaccination rates among older people and other vulnerable groups will have benefits for the individuals themselves as well as health services through avoidable hospital admissions due to severe seasonable influenza and its complications. BJCN Accepted for publication: 24 June 2014 The authors declare that there is no conflict of interest
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other health professionals may need further consideration if vaccination levels are to be improved to meet desired levels of immunity.
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TOPIC HEADER CARE OF THE OLDER PERSON enza vaccination rates of those 60 years and older in the community. Cochrane Database Syst Rev 2010(9): CD005188. doi: 10.1002/14651858.CD005188. pub2 van Delden JJ, Ashcroft R, Dawson A, Marckmann G, Upshur R, Verweij MF (2008) The ethics of mandatory vaccination against influenza for health care workers. Vaccine 26(44): 5562–6. doi: 10.1016/j.vaccine.2008.08.002 Wheelock A, Thomson A, Sevdalis N (2013) Social and psychological factors underlying adult vaccination behavior: lessons from seasonal influenza vaccination in the US and the UK. Expert Rev Vaccines 12(8): 893–901. doi: 10.1586/14760584.2013.814841 While AE (2014) Are nurses fit for their public health role? Int J Nurs Stud. In press. http://tinyurl.com/p2xl5g5 (accessed 15 May 2014) While AE, George C, Murgatroyd B (2005) Promoting influenza vaccination in older people: rationale and reality. Br J Community Nurs 10(9): 427–30 Willis BC,Wortley P (2007) Nurses’ attitudes and beliefs about influenza and the influenza vaccine: a summary of focus groups in Alabama and Michigan. Am J Infect Control 35(1): 20–4 World Health Organization (2014) Influenza (seasonal). Fact sheet no. 211. http://tinyurl.com/cmj8ty (accessed 11 April 2014) Xakellis GC (2005) Predictors of influenza immunization in persons over age 65. J Am Board Family Pract 18(5): 426–33
Kwong EW, Lam IO, Chan TM (2009) What factors affect influenza vaccine uptake among community-dwelling older Chinese people in Hong Kong general outpatient clinics? J Clin Nurs 18(7): 960–71. doi: 10.1111/j.13652702.2008.02548.x Lam P-P, Chambers LW, MacDougall DMP, McCarthy AE (2010) Seasonal influenza vaccination campaigns for health care personnel: systematic review. CMAJ 182(12): E542–8. doi: 10.1503/cmaj.091304 Mangtani P, Breeze E, Stirling S, Hanciles S, Kovats S, Fletcher A (2006) Crosssectional survey of older peoples’ views related to influenza vaccine uptake. BMC Public Health 6(1): 249 Monto AS, Ansaldi F, Aspinall R et al (2009) Influenza control in the 21st century: optimizing protection of older adults. Vaccine 27(37): 5043–53 Nagata J, Hernandez-Ramos I, Kurup A, Albrecht D, Vivas-Torrealba C, FrancoParedes C (2013) Social determinants of health and seasonal influenza vaccination in adults ≥65 years: a systematic review of qualitative and quantitative data. BMC Public Health 13(1): 388. doi:10.1186/1471-2458-13-388 O’Reilly FW, Cran GW, Stevens AB (2005) Factors affecting influenza vaccine uptake among health care workers. Occup Med 55(6): 474–9 Onder G, Liperoti R, Bernabei R, Landi F (2008) Case management, preventive strategies, and caregiver attitudes among older adults in home care: results of the ADHOC study. J Am Med Dir Assoc 9(5): 337–41. doi: 10.1016/j. jamda.2008.02.002 Potter J, Stott DJ, Roberts MA et al (1997) Influenza vaccination of health care workers in long-term-care hospitals reduces the mortality of elderly patients. J Infect Dis 175(1): 1–6 Prior L, Evans MR, Prout H (2011) Talking about colds and flu: the lay diagnosis of two common illnesses among older British people. Soc Sci Med 73(6): 922–8. doi: 10.1016/j.socscimed.2010.09.054 Public Health England (2014a) Seasonal flu vaccine uptake in GP patients 1 September 2013 to 31 January 2014. Statistics. http://tinyurl.com/ozc23zt (accessed 14 April 2014) Public Health England (2014b) Seasonal flu vaccine uptake in healthcare workers 1 September 2013 to 31 January 2014. Statistics. http://tinyurl.com/ pz4ovhj (accessed 14 April 2014) Rubin GJ, Potts HW, Michie S (2010) The impact of communications about swine flu (influenza A H1N1v) on public responses to the outbreak: results from 36 national telephone surveys in the UK. Health Technol Assess 14(34): 183–266. doi: 10.3310/hta14340-03 Stewart AM (2009) Mandatory vaccination of health care workers. N Eng J Med 361(21): 2015–17 Thomas RE, Jefferson T, Lasserson TJ (2010a) Influenza vaccination for healthcare workers who work with the elderly. Cochrane Database Syst Rev 2010(2): CD005187. doi: 10.1002/14651858.CD005187.pub3 Thomas RE, Russell M, Lorenzetti D (2010b) Interventions to increase influ-
KEY POINTS
w Older adults aged 65 years and over are particularly vulnerable to influenza
w Influenza vaccination uptake can be influenced by the system of vaccination, vaccination mistrust and fear of side-effects, as well as health beliefs and behaviours w Interventions to increase community demand and access and provider, system-based and societal interventions can help maximise influenza vaccination uptake among older people w Improved knowledge on ways of overcoming barriers to influenza vaccination uptake may help to translate community nurses’ attitudes, beliefs and behaviours into their professional practices with their patients
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