Promotional communications for influenza vaccination: a systematic review.

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Promotional Communications for Influenza Vaccination: A Systematic Review a

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Laura MacDonald , Georgina Cairns , Kathryn Angus & Marisa de Andrade

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Institute for Social Marketing, Stirling Management School, University of Stirling , Stirling , Scotland, United Kingdom Published online: 03 Dec 2013.

To cite this article: Laura MacDonald , Georgina Cairns , Kathryn Angus & Marisa de Andrade (2013) Promotional Communications for Influenza Vaccination: A Systematic Review, Journal of Health Communication: International Perspectives, 18:12, 1523-1549, DOI: 10.1080/10810730.2013.840697 To link to this article: http://dx.doi.org/10.1080/10810730.2013.840697

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Journal of Health Communication, 18:1523–1549, 2013 Copyright © Taylor & Francis Group, LLC ISSN: 1081-0730 print/1087-0415 online DOI: 10.1080/10810730.2013.840697

Promotional Communications for Influenza Vaccination: A Systematic Review

Downloaded by [Thammasat University Libraries] at 17:38 08 October 2014

LAURA MACDONALD, GEORGINA CAIRNS, KATHRYN ANGUS, AND MARISA DE ANDRADE Institute for Social Marketing, Stirling Management School, University of Stirling, Stirling, Scotland, United Kingdom The authors conducted a systematic review that aimed to map current practice and identify effective practice in promotional communications for seasonal influenza vaccination in Europe. They identified 22 studies from 7 European countries. Included studies were primarily outcome evaluations of communications promoting vaccination to health care workers and elderly adults. Evidence on communications to improve public acceptance was sparse. A range of communication approaches, methods, materials, and channels were used, frequently in combination. All forms of promotional communications have the potential to increase uptake in health care workers and can also improve uptake among patients. There was promising evidence that mass communication methods, delivered as standalone activities or as one component of a communication mix, can improve uptake in target populations. Education for health care workers and improved service delivery are common adjuncts to promotional communications that were associated with effectiveness. The evidence suggests that personalized communications, combined with improved service delivery, might boost rates of uptake among elderly adults. Future development of good practice could be enhanced by more systematic, theory-based intervention design and more detailed reporting of process and outcome evaluations. Vaccine hesitancy is increasingly prevalent; more policy and research to improve public acceptance should therefore be considered.

Influenza causes significant mortality and health complications, particularly in “risk groups” (Monto, 2008). Recognized risk groups for seasonal influenza vaccination are elderly adults and people with underlying medical conditions, and studies have shown that influenza vaccination of people in these groups can reduce morbidity, hospitalization, and mortality associated with the virus (Jefferson et al., 2005). Seasonal influenza vaccination for risk groups is therefore a public health policy objective in most European countries (Mereckiene et al., 2010). In many European countries, influenza vaccination is also recommended for health care workers (HCWs) for three main reasons: HCWs are at risk of infection from occupational exposure; infected HCWs can transmit the virus to patients; and staff absenteeism resulting from influenzarelated HCW illness can significantly disrupt health services (Burls et al., 2006). This research was funded by the European Centre for Disease Prevention and Control (ECDC). The authors thank Laura Walker, Theodora Cairns-Haylor, and Timothy Bowdler for their invaluable assistance with the original systematic literature review on which this article is based. The authors also thank Diane Dixon for her help with formatting and referencing. Address correspondence to Georgina Cairns, Institute for Social Marketing, Stirling Management School, University of Stirling, Stirling FK9 4LA, Scotland, United Kingdom. E-mail: [email protected]

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A 2009 survey of national public health institutes of 27 European Union member states, Norway, and Iceland found that many countries had suboptimal influenza vaccination uptake among risk groups in the 2007–2008 influenza season and failed to meet World Health Organization target immunization rates (Mereckiene et al., 2010). The survey also found suboptimal uptake among HCWs, with reported rates as low as 13.4% in the United Kingdom (Mereckiene et al., 2010). The reasons behind HCWs’ and risk groups’ low uptake of influenza vaccination or “immunization hesitancy” are not fully understood. Promotional communications are frequently and widely used to encourage vaccination uptake. We therefore carried out a systematic literature review (SLR) of promotional communications for national immunization schedule vaccinations in Europe. The purpose of the review was to provide evidence-based support for promotional communications policies and practice. Specific research objectives were (a) to map current practice, (b) to identify practice associated with positive effects, and (3) to synthesize these findings and draw tentative conclusions on their implications for future policy planning and development of good practice. Seven policy-oriented research questions were developed to meet these objectives. The search and screening strategy was designed to capture descriptive and evaluated current practice in the European region. We used critical analysis of identified studies to identify evaluation studies capable of contributing reliable evidence on effective and ineffective promotional communications. Findings from the mapping and analysis were recorded in data extraction tables and summarized as narrative answers to the research questions. Key findings and evidence gaps were then synthesized to provide an overview of current trends and insight on how future policy might best support the development of good practice. A published report with full details of methods, results, and analysis is available at http://ecdc.europa.eu/en/publications/Publications/Literature-review-national-immunisation-schedule-promotional-communications.pdf (Cairns et al., 2012). For the purposes of the SLR, we defined promotional communications as any message, delivered through any channel, intended to encourage or promote vaccination, including informational and educational communications interventions wherein the primary purpose was to increase immunization uptake rates. This article reports on the findings of the SLR that relate to influenza vaccination only. We addressed the following research questions: 1. Which audiences have been targeted? 2. What communication methods and approaches have been used? 3. What theoretical underpinnings have been used to inform communication methods and approaches? 4. What settings and communication channels have been used? 5. What is the evidence for the effectiveness in changing or reinforcing knowledge and attitudes? 6. What impact have influenza vaccination promotional communications had on public acceptance and vaccine uptake rates? 7. What is the evidence for the impact on the prevention and control of influenza?

Method We used systematic review methods to identify, analyze, and synthesize data.


Influenza Vaccination

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The SLR followed a detailed protocol, formalized in advance. We designed the search strategy to identify existing evidence on promotional communications interventions for all vaccines specified in European countries’ national immunization schedule and for seasonal influenza vaccination (Cairns et al., 2012). A search strategy was developed to identify relevant academic and gray literature from 2000 to 2011. We ran searches in 9 subscription academic databases and 17 open-access databases and websites from March to May 2011. As appropriate, title, abstract, and keyword searches were used, combining controlled terms relevant to the database and free text terms. Search strategies combined three types of terms: diseasespecific and immunization terms (e.g., flu, influenza, immunization, vaccine) AND promotional communications terms (e.g., program, advert, message, communication, campaign) AND outcome terms (e.g., knowledge, attitudes, uptake, coverage). Please see the full SLR report for a sample search strategy. Simplified searches were used in databases and websites that did not support advanced searching. Internet searches were run on Google, using selected search terms to identify relevant publications available online. In addition, two journals, Vaccine and Infection Control and Hospital Epidemiology, were hand-searched from 2000 onwards to identify further relevant studies that were neither indexed by the databases nor identified by the search strategy. Search results were imported into the systematic review software EPPI-Reviewer 4 (Thomas, Brunton, & Graziosi, 2010) and duplicates were removed. In the first stage of relevance appraisal, four reviewers screened the title and abstract of studies stored in EPPI-Reviewer 4 against the exclusion criteria listed in Table 1. Second-round screening applied the same exclusion criteria to the full text of studies that were not excluded in the first round screening. Studies that were not excluded at the second round screening stage were included for review. The flowchart in Figure 1 outlines the screening processes applied to the 27,797 items identified by the literature searches that ultimately led to the inclusion of 33 studies in the SLR. Eleven studies are not reported in this article because they were evaluations of promotional communications interventions for vaccinations other than influenza. Two reviewers who were trained to capture the relevant data and who were tested for interrater reliability carried out data extraction of the studies. Questions 1–4, which were drafted primarily to map practice, were answerable using descriptive data. Questions 5–7 required a two-stage assessment: qualitative then quantitative analysis. Table 1. Specified exclusion criteria • Off topic—does not relate to human immunization • Published before 2000 • Not a primary study (e.g., review, editorial, background discussion, economic evaluation using secondary data, modeling study) • Study does not evaluate the effect of promotional communication to inform and influence decisions regarding routine immunization • Study does not report a behavioral or behavioral precursor outcome (including but not restricted to immunization uptake rates, intention to immunize, promotional campaign awareness, knowledge or comprehension of key communication messages, and acceptance of key communication messages) • Study does not partially or wholly include or affect populations from specified European countries or territories


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L. MacDonald et al.

Figure 1. Systematic literature review screening process.

Step 1 was an assessment of validity of identified studies. We used Glynn’s (2006) critical appraisal tool, the Evidence-Based Librarianship Critical Appraisal Checklist. This checklist was identified in a recent review of critical appraisal tools as one of the few tools in peer-reviewed publication designed to be applicable to all research designs (Crowe & Sheppard, 2011). It has been validated for content, and its creator provides a comprehensive guide for its use (Crowe & Sheppard, 2011; Glynn, 2006). For the purposes of the SLR, studies rated with a validity score of 70% or greater were classified as high validity, and studies with a score of less than 70% were rated as low validity. Step 2 was an assessment of weight of evidence for all studies scored as high validity. The evaluation studies identified in the SLR were highly heterogeneous in their purpose, measurement methods, and reporting formats, which not only precluded the option to meta-analyze data, it also meant that a rigorous but also sensitive approach was required to sort studies into those reporting evidence of positive effect or no effect. To achieve this, we used Cohen’s (1988) guidelines on interpreting behavioral science statistics to assess magnitude of effects, and as recommended by Cohen (1988), we considered effect size and significance levels to identify reliable evidence of effectiveness. For example, we classified interventions as evidence of effectiveness if they reported at least one positive effect size classified by Cohen as small or greater and no negative effects on knowledge, attitudes, or behavior outcomes at statistically significant levels (p ≤ .05). Interventions that reported no evidence of positive effects, a mix of negative and positive effects, or only effect sizes classified by Cohen as trivial at any significance level were classified as no evidence of effectiveness.


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Reporting of mapping and assessment of evidence for effectiveness results are reported in the Results section, and tentative conclusions on their implications for future policy planning (Objective 3) are outlined in the Discussion section.


Results We identified 22 evaluation studies of promotional communications interventions for influenza immunization: 9 from the United Kingdom, 4 in Switzerland, 2 in Spain, 2 in Sweden, 2 in The Netherlands, 2 in France, and 1 in Greece. The large proportion of studies from the United Kingdom might represent some level of bias in the SLR because it was restricted to English-language studies. We scored 12 of these studies as high-validity studies, and 7 of these reported evidence of effectiveness. Table 2 presents brief descriptions of intervention aims, target groups, intervention approaches, communication channels, and results of the 22 studies, along with the validity assessment (high/low), and the weight of evidence assessment for the highvalidity studies. In the following sections we summarize the main findings for each of the seven research questions. Current Practice Which Audiences Have Been Targeted? Of the 22 studies, 10 were evaluations of promotional communications interventions targeting HCWs only. Six studies reported evaluations of interventions targeting clinical risk groups. Four interventions targeted HCWs and clinical risk groups, and two targeted the general public. Most of the interventions that targeted HCWs aimed to directly increase vaccination uptake among HCWs or to mediate increased uptake in risk groups by working through HCWs. All interventions that targeted risk groups aimed to directly increase uptake. What Communication Methods and Approaches Have Been Used? The approaches used in the interventions included in the SLR were categorized as follows: • Mass communication (distribution of universally targeted information to undifferentiated or large segments the population at the same time). • Personalized communication (which aims to make a personally relevant appeal to individuals by, for example, using direct contact or individually addressed correspondence). • Training/education. The categories are not always clearly delineable. An intervention that took a mass approach might have been perceived as relevant and personal by the audience, particularly if segmentation was used, for example, in the method of establishing contact. The intervention evaluated by Llupia and colleagues (2010) included educational and advertising messages that were e-mailed to HCWs on a weekly basis. The recipients might have perceived this form of communication to be personal and relevant even though the messages were sent as part of a mass campaign. The categories are also not mutually exclusive, and many interventions combined more than one approach. For example, the intervention evaluated by Sartor

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To explore the effect of health information on general public’s intention to be immunized

To increase influenza vaccination uptake in patients 75 years of age and older

Arthur et al. (2002) • Large general practice, United Kingdom

Chanel et al. (2011) • France


Aim (target group in bold)

Arthur (2001) • General practices, United Kingdom

Author(s) and setting

Table 2. Included studies

Before and after study • A nurse home visit was designed to carry out a general health assessment during which patients were offered influenza vaccination. Randomized controlled trial • One third of GP practice patients were randomized to receive an offer of influenza vaccination as part of an health check for adults 75 years of age and older administered by a practice nurse in the patient’s home. • Two thirds of patients were randomized to receive a personal letter of invitation to attend an influenza vaccination clinic held at the practice. Before and after study • At each of five successive stages, participants used an electronic voting system to vote on their intention to be vaccinated in response to a question/prompt or other information. • Collective results were disclosed, and participants were given the opportunity to change their vote before moving on to the next stage (social norms feedback).

Study design and intervention

No significant change in the proportion of those who did intend to be immunized and those who did not across the first four stages. At the last stage, there was a significant decrease in the proportion of those who did not intend to be immunized (average of 75% in the first four stages; 55% in the last stage), and a significant increase in the proportion of those who did intend to be immunized (from an average of 19% to 32%). Over the first four stages, there was no significant change in the proportion of

Influenza immunization uptake among adults older than 75 years of age increased from 38.3% (n = 149) in the year before the intervention to 57.5% (n = 224) during the intervention year. Level of significance not reported. 67.9% (n = 932) of those sent a personal letter were vaccinated. 74.3% (n = 505) of those offered a combined health check and influenza vaccination (difference 6.4%; 95% CI 2.2%–10.4%; p = .003). Restricting analysis to those who had not been vaccinated in the previous year, uptake rates were lower in the nurse health check group (56.2% [196/349]) and the personal letter group (44.0% [322/731]), but the difference between the groups was greater (12.1%; 95% CI 5.8%–18.4%; p < .001).

Results


• Low • N/A

• High • Evidence of effectiveness


Validity classification and weighted evidence

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Dey et al. (2001) • Nursing homes and primary care settings, England

de Juanes et al. (2007) • University Hospital, Spain

To increase HCW influenza immunization uptake

To increase HCW influenza vaccination uptake

Interrupted time series • 2001–2002 and 2002–2003: Mass communication campaign consisting of informational posters and information sheets. • 2003–2004: Recommendation for vaccination printed in internal hospital bulletin. • All hospital departments actively visited by a doctor or nurse to offer vaccination in the workplace to HCWs. Cluster randomized controlled trial • Intervention settings visited by a public health nurse who provided information about immunization, including details about efficacy and safety, possible side effects and contraindications, and attempted to allay anxiety and correct

participants who did not change their mind about their intention to immunize (average 81%). In the last stage, the proportion of people whose intention remained constant (i.e., did not change their mind) decreased to 57% (p < .0001). The proportion of positive changes (i.e., changed from intention not to immunize to intention to immunize) increased from less than 10% to 38% (p < .001) and the proportion of negative changes decreased from more than 10% to 6% (p = .0039). A significant increase in immunization uptake was observed among all professional groups over the three seasons: 15.9% (n = 899) vaccinated in 2001–2002 21.4% (n = 1,215) vaccinated in 2002–2003 40.4% (n = 2,287) vaccinated in 2003–2004 (p < .01) Adults vaccinated in a previous campaign were more likely to be vaccinated in future campaigns: OR = 9.1 (95% CI 7.8–10.7) and OR = 3.9 (95% CI 3.4–4.4) for 2002–2003 and 2003–2004, respectively. No significant differences in immunization uptake between intervention and control groups 2 months after intervention. For primary care mental health teams, 21.9% (n = 100) intervention and 21% (n = 83) control (p = .091).


(Continued)

• High • No evidence of effectiveness


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Hak et al. (2000) • General practices, The Netherlands


Table 2. Continued

To improve HCW (general practitioners) influenza immunization practices and to increase overall influenza immunization uptake in patients

Aim (target group in bold) misconceptions. Nurses disseminated promotional materials and informed HCWs where they could receive fee vaccination. Before and after study with a nationwide collaborative prevention program • At the national level, GP influenza guidelines advocated; a team of experts employed at GP organizations to integrate primary health care procedures; materials such as reminder cards, patient education brochures and organizational information for GPs developed; further financial arrangements concerning reimbursement made. • At the GP district level, continuing medical education and smallgroup consensus meetings organized for GPs and practice assistants; a district coordinator appointed to facilitate the management of preventative activities. • At the GP practice level, district facilitators supported individual GPs in adopting the immunization guidelines by helping to improve practice


Overall influenza immunization uptake in patients increased from 9.1% before the program to 16.3% (p < .001) after. The study found significant increases in the proportion of GP practices who reported incorporating immunization guideline procedures into practice.

For nursing home staff, 10.2% (n = 78) intervention and 5.6% (n = 77) control (p = .34).

Results


• Low • N/A


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Humair et al. (2002) • Primary care clinic, university, hospital, Switzerland

Hull et al. (2002) • Three general practices, England



Before and after study • Print informational materials for patients about influenza immunization placed at clinic reception desk and in waiting areas. A walk-in, low-cost immunization clinic to provide an easy, quick, and cheap service to patients. A 1.5-hr training workshop for physicians to teach them about key aspects of influenza vaccination, particularly national recommendations and practical counseling strategies. Twicemonthly peer comparison

organization and coordination and assisting with using computerized registration and supportive software. Randomized controlled trial • Telephone call from the practice receptionist to intervention group households offering an appointment for influenza immunization at a nurse-run clinic. The intervention coincided with a local authority Mailshot urging adults older than 65 years of age to contact their GP for vaccination and with a national television campaign to promote vaccination. Of the patients who made a telephone appointment, 88% were immunized, whereas 22% of those who did not accept an appointment went on to be immunized Influenza immunization uptake of patients 65 years of age and older increased from 21.7% before the intervention to 51.7% after overall. In patients who attended the clinic only before the intervention, immunization uptake was 15.5%, compared with uptake of 39.1% among patients who attended the clinic only during the intervention (adjusted RB = 2.8; 95% CI 1.8–4.4). In patients who attended the clinic before and during the intervention period, immunization uptake increased from 29.2% to 69.4% (RB = 2.4; 95% CI 1.9–3.0). The most significant increases in immunization rates occurred among patients with lower initial coverage: younger elderly adults

The immunization rate in the control group was 44%, compared with 50% in the intervention group (OR = 1.29; 95% CI 1.03–1.63). The unadjusted difference between control and intervention groups in the proportion of individuals immunized was statistically significant at 5.9% (95% CI 0.5%–11%; p = .031). The adjusted difference was 6.3% (p = .026).


(Continued)



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Llupia et al. (2010) • University hospital, Spain

Table 2. Continued

feedback to physicians on their individual and collective performance in the vaccination of patients in the target group. Reminder stickers for application on medical records of patients for whom immunization was recommended available in all consultation rooms Before and after study • Annual seasonal influenza vaccination campaign since 2004 included educational advertising material on the basis of posters placed in strategic sites and visible institutional support by means of an e-mail to all HCWs, and free influenza vaccination. In the 2008–2009 campaign, strategies were introduced to promote peer-to-peer communication among HCWs, involving increased institutional support; raising interest in vaccination through discussions—awareness was spread through weekly educational and advertising messages sent by e-mail, prize draws for vaccinated HCWs, and


Overall coverage achieved: 2008–2009: 37.0% (95% CI 34.7%–37.4%) 2007–2008: 23.7% (95% CI 22.5%–24.9%) Vaccination rates for physicians highest: 2007–2008: 32.5% 2008–2009: 51.1% Vaccination rates for nurses lowest: 2007–2008: 23.7% 2008–2009: 30.7%

between 65 and 75 years of age (adjusted RB = 5.7; 95% CI 2.7–12.4), new patients (adjusted RB = 8.6; 95% CI 2.6–28.3) and men (adjusted RB = 3.9; 95% CI 1.9–7.9).

Results




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Luthi et al. (2002) • Vaud Canton, Switzerland

Looijmans van den Akker et al. (2010) 33 nursing homes, The Netherlands

To increase influenza vaccination uptake in patients 65 years of age or older


a webpage titled, “I’ve already been vaccinated” with staff photographs; and enhancing accessibility by increasing numbers of vaccination mobile unit staff. Cluster randomized controlled trial • A multifaceted intervention program consisting of three main components: an outreach visit by the primary researcher during which the homes received a script of the program, all required materials (personal invitation letters for the meetings, information leaflets, posters, reference to the intervention website) and background information; a plenary 1-hr information meeting (organized twice in each home) by a specialized nurse of the local municipal health center (including discussion in small groups and video with role models); and appointment of a local program coordinator (preferably a physician). Before and after study • The Canton Health Department implemented a population-based influenza prevention program among adults older than 65 years of age. The main activities were information meetings about influenza vaccination Vaccination coverage: Before intervention: 58.0% (95% CI 56.2%–59.8%) After intervention: 58.4% (95% CI 56.6%– 60.2%) Not significant (p = .757) There was a statistically significant increase (6.5%) in vaccination coverage was observed

Vaccination rate for HCWs: Intervention group: 25% Control group: 16% Difference of 9% (RR = 1.59; 95% CI 1.08–2.34; p = .02)


• Low • N/A

(Continued)


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Malmvall et al. (2007) • Jönköping County, Sweden


Table 2. Continued

To increase influenza vaccination uptake in patients 65 years of age or older and in medical risk groups


Interrupted time series • The 3-year multifaceted campaign started in 2002 and included free vaccination for adults 65 years of age or older; a multiprofessional campaign team; annual education meetings in each of the county’s three districts focusing on nurses in the primary health care organization; a media campaign designed by professional marketing and public relations experts using TV and newspaper advertisements; posters in waiting rooms and pharmacies; leaflets in health centers; a web-based registry that allowed health centers

among associations for elderly adults, and for the staff of sociomedical institutions and services. Information tools were developed, such as a video, information leaflets, brochures, articles in the lay press, a website and a press conference. In addition, information was transmitted by the local TV network.

Study design and intervention in adults 65 to 69 years of age (p = .008). Immunization coverage: For those who had home visit from a social worker (nurse or other family help): 74.7% For those who had no home visit from social worker: 55.4% (p = .001) In 2000, these figures were, respectively, 76.0% and 56.0% (p = .001). 52.7% of all respondents in the postintervention survey knew about the program. Among the program used to increase vaccination coverage, the brochure “La Grippe se Sert de Vous” had the most impact (28.7%). Immunization rates in adults older than 65 years of age in Jönköping County: 2000: 45% 2005: 70% (no p value reported) Immunization rates in adults 65 years of age and older in Jönköping County: 1999: 39% 2000: 45% 2001: 52% 2002: 59% 2003: 66% 2004: 68% 2005: 70%

Results




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Natter and Berry (2005) • United Kingdom

Maltezou et al. (2007) • Public hospitals, Greece

To evaluate the effect of the provision of information about the baseline level of risk on general public’s interpretation of relative and absolute risk reductions


to monitor their results and compare them with other health centers; and performance feedback to primary health nurses. Starting in 2005, the same activities continued as standard practice rather than as part of a special campaign project. Before and after study • A nationwide campaign by the Hellenic Centre for Disease Control and Prevention. In September 2005, the center sent leaflets on influenza immunization, educational materials, and information on vaccination strategies to all Greek hospitals Randomized trial (no control group) • Four different booklets outlining the fictitious scenario of a severe influenza epidemic expected to hit Britain in the coming months. In all booklets, people were advised that they should be vaccinated. The booklets contained different combinations of information about baseline risk, relative risk reduction, and absolute risk reduction. • Booklet 1: Information about baseline risk (“It is predicted Intention to immunize: Booklet 1: M = 3.61 (SD = 1.2) Booklet 2: M = 2.29 (SD = 1.0) Booklet 3: M = 3.41 (SD = 1.3) Booklet 4: M = 3.73 (SD = 1.2) Significant effect of baseline: p < .01 Significant effect of risk: p < .01 Significant interaction: p < .001 Analysis of the interaction showed that ratings were significantly higher in the relative format condition, but only when participants were not informed about the baseline. Perceived effect of immunization: Booklet 1: M = 3.71 (SD = 1.1) Booklet 2: M = 2.41 (SD = 1.2) Booklet 3: M = 3.56 (SD = 1.2)

Immunization uptake in the 2005–2006 influenza season varied by HCW profession, type of hospital, size of hospital, and region of Greece.

Influenza vaccination rate in HCWs: 2005–2006 season: 16.36% 2004–2005 season: 1.72% (self-reported rate) Level of significance not reported


• Low • N/A

• Low • N/A

(Continued)

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Nuttall (2003) • General practice, England


Table 2. Continued


Aim (target group in bold) that 10% of the adult population (i.e., 10 out of every 100 adults) will be affected by the flu”) and absolute risk reduction information (“With vaccination, the risk of being affected by the flu is 5% lower”). • Booklet 2: Absolute risk reduction information, but no information about baseline risk. • Booklet 3: Information about baseline risk and relative risk reduction information (“With vaccination, the risk of being affected by the flu is reduced by 50%”). • Booklet 4: Relative risk reduction information, but no information about baseline risk. Randomized controlled trial • Three intervention conditions: o Group 1: received a letter from the local health authority inviting them to attend their GP surgery for influenza immunization (usual practice). o Group 2: received invitation letter plus a copy of the Department of Health leaflet “Flu Jab—Beat Flu, Use a Jab.”


Immunization rates of patients: Group 1: 27% Group 2: 23% Group 3: 40% Difference in immunization rates between the three groups was not significant (p = .329). Subdivision of each intervention group into those participants younger than 72 years of age showed little difference in uptake and no significant difference between the three intervention groups (p = .914). Immunization uptake among patients 72 years of age and older was greater in group 3 (33%) than in

Booklet 4: M = 3.59 (SD = 1.1) Significant effect of baseline: p < .001 Significant effect of risk: p < .05 Significant interaction: p < .001 Analysis of the interaction showed that ratings were significantly higher in the relative format condition, but only when participants were not given information about the baseline.

Results




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Sartor et al. (2004) • University Hospital, France


o Group 3: received invitation letter and home visit from a health visitor to discuss the influenza vaccination program. The health visitor ensured the information was consistent by providing facts taken from the leaflet, given in the same order at every visit. • Patients were invited to ask questions and the health visitor’s responses were based on information from Department of Health literature. Interrupted time series • A mobile cart influenza vaccination program providing vaccine directly to hospital units. To increase awareness of the information campaign, articles were published in the monthly infection control newspaper delivered to each physician and unit of the hospital, announcements were published in a letter personally addressed to each physician and each head nurse, posters were located throughout the hospital, and there were additional education sessions for units with low vaccination uptake. Unvaccinated staff members were educated by the vaccination team about the A significant increase in the overall influenza vaccination rate for HCWs: 1998: 6% (134/2,298) 1999: 7% (158/2,349) before the mobile cart program was introduced 2000: 32% (753/2,381) 2001: 35% (837/2,420) 2002: 32% (771/2,418) after the mobile cart program was introduced (p < .001)

group 1 (7%) or group 2 (7%); the difference was not significant (p = .067).


• Low • N/A

(Continued)

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To increase influenza and pneumococcal vaccination uptake in patients 65 years of age or older and medical risk groups

To increase influenza vaccination uptake in patients 65 years of age or older and medical risk groups

Scottish Executive (2007) • Scotland


Scottish Executive (2005) • Scotland


Table 2. Continued

benefits of the vaccine, adverse reactions, the epidemiology of nosocomial influenza in the setting during the past, and the effect of immunization of HCWs on the protection of patients. The employee health service annual vaccination campaign continued as normal. Interrupted time series • The Scottish Executive runs a yearly campaign to promote uptake of seasonal influenza vaccination. In 2003, the campaign was extended to include the promotion of pneumococcal vaccination. The 2003–2004 campaign used terrestrial TV, national and regional press, and local commercial radio. Interrupted time series • In 2006–2007, for the first time, the Scottish Executive’s annual influenza vaccination campaign ran in two phases targeting different audiences. • The first phase in October 2006 targeted adults older than 65 years of age and used television advertising.


Spontaneous campaign awareness in at-risk adults: 2003: 69% 2005: 79% 2006: 65% Prompted campaign awareness (all respondents were played the radio advertisement in full and shown a picture of the poster advert from the current campaign) in at-risk adults: 2003: 72%

Participants’ awareness of the term pneumococcal: At baseline: 21% At first postcampaign survey: 50% At second postcampaign survey: 33% Among those aware of the term pneumococcal at baseline, 10% correctly described it (unprompted) as a cause of pneumonia. At the first and second postcampaign evaluations, 31% and 20% did so, respectively.

Results


• Low • N/A

• Low • N/A


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Siriwardena et al. (2002) • General practices, England


• The second phase in November/ December 2006 targeted the at risk adults and used radio, outdoor posters, panels on public transport, leaflets in doctors’ surgeries and pharmacy bags. This phase did not use television advertising. The main campaign message was about the consequences of contracting influenza virus. Specifically, the advertising communicates the message “At 100 mph, flu can hit you hard, make sure you get your free flu jab.” Cluster randomized controlled trial • An educational outreach visit to intervention practices by a research GP that took no longer than 1 hr. The visit involved provision of evidence-based information; presentation of both sides of controversial issues; encouragement of active learning; use of simple overheads and graphs; and emphasis of essential messages. The educational element was a dialogue around perceived barriers to vaccination within the organization. There was also discussion about techniques to improve adult vaccination rates, with a summary of the evidence of effective interventions. Improvements in pneumococcal vaccination rates in the intervention practices were significantly greater compared with controls in patients with coronary heart disease, 14.8% vs. 6.5% (OR = 1.23; 95% CI 1.13–1.34) increase, and diabetes, 15.5% vs. 6.8% (OR = 1.18; 95% CI 1.08–1.29) increase; but not splenectomy, 6.5% vs. 4.7% (OR = 0.96; 95% CI 0.65–1.42) increase. Improvements for influenza vaccination were also greater in intervention practices than in control practices but did not reach statistical significance: Coronary heart disease: 18.1% vs. 13.1% (OR = 1.06; 95% CI 0.99–1.12; p = .08) increase Diabetes: 15.5% vs. 12.0% (OR = 1.07; 95% CI 0.99–1.16; p = .09) increase Splenectomy: 16.1% vs. 2.9% (OR = 1.22; 95% CI 0.78–1.93; p = .38) increase Although not significant, influenza vaccination

2005: 90% 2006: 68%


(Continued)


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Tapiainen et al. (2005) • University Children’s Hospital, Switzerland

Stenqvist et al. (2006) • Vastra Gotland Region, Sweden


Table 2. Continued




Interrupted time series • The Department of Communicable Disease Control implemented a program in the Gothenburg area in 1999 that was expanded to the whole Region in 2001. Every September, repeated 3-hr information sessions were held in various locations in the region. HCWs from primary care facilities were invited to attend. Information sessions covered many aspects of influenza and vaccination, both theoretical and practical. Before and after study • Intervention took place between 2003–2004 and 2004–2005 influenza season. All pediatric HCWs received an informal letter with the following information: what is influenza, efficacy of influenza immunization, side effects, patient protection, and real contraindications. Educational

Control practices received audit and feedback alone.


The immunization rate among all HCWs increased: Before intervention: 19% (95% CI 15%–22%) After intervention: 24% (95% CI 20%–28%; p = .03) Among physicians, the immunization rate increased: Before intervention: 43% (95% CI 33%–54%) After intervention: 64% (95% CI 55%–75%; p = .004) Among nurses, the immunization rate did not change significantly:

for patients 65 years of age and older showed a greater increase in control practices than intervention practices, 25.4% vs. 20.7% (OR = 0.99; 95% CI 0.96–1.02; p = .42). No statistics reported for high-risk groups overall The estimated immunization rate in adults 65 years of age and older increased from 33.6% to 54.6% in the Gothenburg area between 1999 and 2004 and from 44.1% to 51.9% in the whole region between 2001 and 2004. There are no reported measures of significance. Respondents’ awareness of recommendation for yearly influenza immunization: 1999: 80.2% 2004: 89.4%

Results



• Low • N/A


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Note. GP = general practitioner; HCW = health care worker.

Toscani et al. (2003) • Geneva Canton, Switzerland

conversations with the head nurses of each ward. Free walk-in immunization clinics opened and extended to wards not located in the main hospital. After walk-in clinics were closed, opportunity for voluntary immunization was directly offered on wards. Interrupted time series • The “United Against Flu” campaign started in 1993, supported by the Health State Department in collaboration with a number of health institutions and professional institutions. • Informational activities as part of the campaign: letters to health professionals and health institutions, press conferences, participation in TV and radio programs and cultural events, on-the-job training activities for health professionals, teaching to students of different health professions, information and education for patient risk groups through clubs and other organizations. • Supporting materials produced as part of the campaign: TV spots, leaflets and posters for the general public and health institutions, promotional materials such as handkerchief packages and stickers, campaign website Reported flu immunization coverage of the Geneva population 65 years of age in 1991–2000 increased significantly from 28.7% (95% CI 25.6%–31.8%) to 58.5% (95% CI 55.5%–61.5%; p < .01) Exact figures not available for 1992–1999

Before intervention: 13% After intervention: 14% after (p = .52) Among other HCWs, the immunization rate did not change significantly: Before intervention: 16% After intervention: 16% (p = 1.00)


• Low • N/A


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and colleagues (2004) combined mass advertising with personally addressed letters to hospital physicians. Some interventions, however, relied on a single communication method. For example, the intervention evaluated by Hull, Hagdrup, Hart, Griffiths, and Hennessy (2002) attempted to increase vaccination uptake in elderly adults by telephone appointment invitations only. Although some of the communications in certain interventions captured by the SLR could be classified as mass communications, they might be somewhat restricted in their reach because of the methods of distribution. The intervention evaluated by Malmvall, Franzen, Abom, and Hugosson (2007), which targeted elderly adults and other patient risk groups, is an example. One of the components of the intervention was campaign posters which were placed in health centre waiting rooms and pharmacies. Poster-based communications are generally classed as a form of mass communications but in this case were likely to reach only those in contact with health facilities and could not have reached all members of the target audience, such as housebound elderly adults. A wide range of personalized communications approaches were captured in the SLR. Face-to-face communications were used mostly for groups of individuals who had not responded to previous opportunities to be immunized. For example, in the intervention evaluated by Arthur and colleagues (2002), elderly patients who had not used clinic-based services were given the opportunity to receive a nurse home visit and an influenza vaccination. In the intervention evaluated by Nuttall (2003), elderly patients who had not been vaccinated against influenza in the previous influenza season received a letter inviting them to attend their general practitioner (GP) surgery for vaccination and a separate home visit from a health visitor to discuss the influenza vaccination program. Only one intervention included in the SLR used e-mail to communicate with HCWs (Llupia et al., 2010). This evaluation was relatively recent, and it is likely that use of electronic communications will become a more frequently used and reported channel in the future. Training and education provision was a component of ten of the included interventions, in all cases provision was directed at HCWs. Eight reported interventions involved some form of improved service delivery such as in-home or workplace vaccination to address structural barriers. For example, in the intervention evaluated by Tapiainen, Bär, Schaad, and Heininger (2005), free walk-in immunization clinics were opened in wards that were not located in the main hospital in order to make access to vaccination easier for HCWs who might have previously had difficulty accessing clinics. Similarly, in the intervention evaluated by Arthur and colleagues (2002), elderly patients were offered vaccination in their own home.

What Theoretical Underpinnings Have Been Used to Inform Communication Methods and Approaches? Many interventions appeared to aim to address psychosocial barriers to vaccination and to positively communicate the benefits. However, few studies explicitly reported that they targeted psychosocial barriers or reported outcome measures relating to this variable. Reported details were often incomplete, so prevalence of this as an objective in current practice cannot be known with certainty. Dey, Halder, Collins, Benons, and Woodman (2001), for example, described an intervention in which public health nurses visited HCW groups to address misconceptions about safety and efficacy of vaccines and to inform HCWs about access to free vaccinations. However, only behavioral (not perceptual) outcome measures were reported.



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The use of theories or models of behavior change to inform and develop interventions were not clearly or explicitly reported in any of the evaluations identified except for the health belief model in the intervention evaluated by Dey and colleagues (2001). The model is based on the assumptions that people will take action to prevent an ill-health condition if they believe that (a) they are susceptible; (b) it could have serious consequences; (c) a course of action available to them would reduce the susceptibility and/or severity of consequences; and (d) that the anticipated barriers to, or cost of, taking the action are outweighed by its benefits. Dey and colleagues (2001) noted that the health belief model has a strong focus on individual responsibility and does not consider structural barriers. They concluded that the health belief model is inappropriate for large-scale immunization uptake because health systems delivery is the primary determinant. They suggested that the theory’s inadequacy might explain the lack of effectiveness for the evaluated intervention. The information deficit model appears to be implicit in the design of many of the included interventions. This model builds on the assumption that vaccine hesitancy is the result of a lack of knowledge and that providing information to overcome this knowledge deficit can shift attitudes and behaviors. However, research has demonstrated that many more complex factors influence attitudes and beliefs and that simply providing people with information does not change attitudes or behaviors (Schultz, 2002). Two formative evaluation studies explored the effect of message framing on intentions to be vaccinated among the general public (Chanel, Staphane, Massoni, & Vergnaud, 2011; Natter & Berry, 2005). These studies did not provide information on practice patterns. They might, however, reflect the growing interest among the public health community in using theory- and evidence-based communication methods. However, we identified only one study that explicitly described the use of specialist communications expertise. Malmvall and colleagues (2007) provided detailed information on the use of marketing and public relations experts to develop a selfsustaining long-term primary health care–based intervention that resulted in a 25% increase in vaccine uptake among elderly patients. What Settings and Communication Channels Have Been Used? All of the interventions that targeted HCWs were based in the workplace. The workplace is a convenient setting to disseminate communications and is often the setting in which HCWs can obtain vaccination. Three interventions that targeted elderly adults involved home visits by HCWs (Arthur, 2001; Arthur et al., 2002; Nuttall, 2003). Improved ease of access to vaccination was a common additional component of the workplace-based interventions that targeted HCWs and the home visit–based interventions that targeted elderly adults. A variety of communication channels were used across the evaluated interventions. For example, printed materials (including letters, leaflets, and posters), and personally addressed invitations to be vaccinated were widely used. Face-to-face communications were a common intervention component. The SLR identified limited use of electronic communications channels, with only one evaluation of an intervention using email to communicate with HCW in a hospital setting (Llupia et al., 2010). The evaluation authors describe the use of website and real-time updates as a social diffusion tool for acceptance, and as the “glue” holding multicomponent interventionstogether, providing a shared identity and feedback to multiple stakeholders.

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Evidence of Effectiveness


To examine for evidence of effectiveness, the analysis was restricted to high-validity studies. What Is the Evidence for the Effectiveness in Changing or Reinforcing Knowledge and Attitudes? All 12 of the high validity studies used vaccination uptake as a main outcome measure, and of these, 7 reported evidence of effectiveness (Arthur, 2001; Arthur et al., 2002; de Juanes et al., 2007; Humair, Buchs, & Hans, 2002; Llupia et al., 2010; Looijmans van-den Akken et al., 2010; Malmvall et al., 2007), and 5 reported no evidence of effectiveness (Dey et al., 2001; Hull et al., 2002; Nuttall, 2003; Siriwardena, Rashid, Johnson, & Dewey, 2002; Tapiainen et al., 2005). None of these intervention evaluations also included knowledge or attitude outcome measures. We identified no direct evidence therefore on whether improved knowledge or positive changes to intention to be vaccinated are predictive of improved vaccine uptake. However, the strong association between education and training for HCWs and increased uptake does suggest that this group at least might be positively responsive to information and attitudinal based interventions (e.g., see Humair et al., 2002). What Impact Have Influenza Vaccination Promotional Communications Had on Public Acceptance and Vaccine Uptake Rates? Public support is essential to achieve good immunization uptake rates but, as noted by authors of some of the included studies, high immunization coverage rates are not an incentive for individuals to be vaccinated. Sartor and colleagues (2004) reported that even HCWs were not motivated to consider their own immunization as a contribution to the herd immunity effect. None of the studies captured by this SLR directly assessed the impact of promotional communications on public acceptance of influenza vaccination. Some studies indirectly provided insight into possible mechanisms for promotional communications to influence public acceptance. The intervention evaluated by Llupa and colleagues (2010), for example, was implemented at the worksite level, not at the general population level, but it indicated that social networks might be a useful channel to improve socially shared acceptance. More research is needed to understand whether this could scale up. Research on whether framing herd immunity messages to emphasize more relevant personal benefits, such as protecting family and friends could improve public acceptance would also be a valuable contribution to the knowledge base. The effect of message framing might be relevant to mass and personalized communications because the affective impact of key messages is expected to be a significant moderating influence on behavioral intentions and outcomes in both approaches (Rothman & Salovey, 1997). Two experimental studies examining the effect of message framing on intentions to be vaccinated were included in the SLR (Chanel et al., 2011; Natter & Berry, 2005). Chanel and colleagues’ (2011) study found no evidence that social-norms feedback changed intentions to be vaccinated. Natter and Berry’s (2005) study reported evidence that provision of risk information presented in a socially and personally relevant way improved intention to be vaccinated. There was some indication that this might have


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been partially due to the influence of normative perceptions. The evidence, therefore, is somewhat mixed. Similarly, a recent meta-analysis of studies examining the impact of message framing on audience response to interventions for promoting vaccination and other disease prevention behaviors failed to identify any persuasive benefits from alternative framing strategies (O’Keefe & Nan, 2012). What Is the Evidence for the Impact on the Prevention and Control of Influenza? None of the studies provided any epidemiological data to assess the impact of promotional communications interventions on disease outcomes. However, we examined evidence of impact of promotional communications on prevention and control measures for specific target groups, communication approaches and methods, as well as settings and channels. We examined effectiveness in terms of impact on vaccine uptake rates among different target audiences. Three interventions aiming to increase uptake in HCWs reported evidence of effectiveness (de Juanes et al., 2007; Llupia et al., 2010; Looijmansvan den Akker et al., 2010), and two reported no evidence of effectiveness (Dey et al., 2001; Tapiainen et al., 2005). Two interventions simultaneously targeting HCW and risk groups reported evidence of effectiveness (Humair et al., 2002; Malmvall et al., 2007). One intervention study targeting HCWs that aimed to indirectly increase uptake in elderly adults reported no evidence of effectiveness (Siriwardena et al., 2002). Of the studies of interventions that targeted risk groups only, two reported evidence of effectiveness (Arthur, 2001; Arthur et al., 2002), and two reported no evidence of effectiveness (Hull et al., 2002; Nuttall, 2003). We compared effectiveness of the three broad approaches in terms of vaccine uptake rates; mass communication; personalized communication; and training/education. The only intervention that took an exclusively mass communications approach reported evidence of effectiveness (de Juanes et al., 2007). Six interventions combined a mass communications approach with other approaches: three reported evidence of effectiveness (Humair et al., 2002; Llupia et al., 2010; Malmvall et al., 2007), and three reported no evidence of effectiveness (Dey et al., 2001; Hull et al., 2002; Tapiainen et al., 2005). Comparative analysis of high-validity studies with regards to communications approaches revealed mixed evidence for the effectiveness of personalized approaches in terms of vaccine uptake rates. Two interventions that adopted an exclusively personalized approach reported evidence of effectiveness (Arthur, 2001; Arthur et al., 2002), and two reported no evidence of effectiveness (Hull et al., 2002; Nuttall, 2003). Three interventions that included a personalized approach combined with other strategies reported evidence of effectiveness in terms of vaccine uptake (Humair et al., 2002; Llupia et al., 2010; Looijmans van-den Akker et al., 2010), and three reported no evidence of effectiveness (Hull et al., 2002; Tapiainen et al., 2005; Nuttall, 2003). The SLR found promising evidence for the effectiveness of training and education for HCW in terms of impact on vaccine uptake. Three interventions that were based on the provision of training and education for HCWs reported evidence of effectiveness (Humair et al., 2002; Loijmans van-den Akker et al., 2010; Malmvall et al., 2007), whereas two reported no evidence of effectiveness (Dey et al., 2001; Siriwardena et al., 2002). Six of the eight interventions that included improved service delivery reported evidence of effectiveness on vaccine uptake (Arthur, 2001; Arthur et al., 2002; de Juanes et al., 2007; Humair et al., 2002; Llupia et al., 2010; Malmvall et al., 2007), and two


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reported no evidence of effectiveness (Dey et al., 2001; Tapiainen et al., 2005). De Juanes and colleagues’ (2007) study evaluated an intervention which included visits from a doctor or nurse to all hospital departments to offer influenza vaccination to HCWs in the workplace. This proactive strategy to make vaccination more accessible was associated with a significant increase in uptake. Of the four high-validity interventions that did not include improved service delivery, only one reported evidence of effectiveness (Looijmans van-den Akken et al., 2010). Overall, in terms of methods and approaches, the evidence indicates that improved service delivery is associated with positive intervention effect, but might not always be necessary, nor is it sufficient on its own. We examined the evidence for effectiveness of the various communication channels used across the evaluated interventions, but there was no clear pattern indicating which channels are associated with effectiveness.

Discussion Most of the studies included in the SLR were evaluations of real-world interventions, with vaccine uptake the most common outcome measure. The identified studies provide good insight into current practice in Europe but more limited evidence on best practice. A range of communication approaches, methods, materials and channels have been used to promote seasonal influenza vaccination. There was evidence that all were associated with positive outcomes, but not consistently. Most interventions use a combination of approaches, methods, materials, and channels. The heterogeneity of methods and approaches in the interventions captured in the SLR might reflect the broad scope of target audiences and settings that current practice faces. It might also demonstrate a lack of consensus on good practice. Few studies have provided information on theoretical underpinnings that shaped intervention design. None of the evaluations measured the effect of modification of individual intervention variables. This shortcoming limits the firm conclusions that can be drawn in terms of which communication mixes might be optimal or ineffective. More detail on the conceptual assumptions underpinning intervention design and delivery as well as implementation process data would be helpful to future policy and practice development. There was evidence that investing in specialist expertise in communications to design and develop interventions should be considered (Malmvall et al., 2007). Specialist communication skill might not only result in effective immediate outcomes, but also more sustained effects than interventions developed from within health care systems (Abraham, 2009; Malmvall et al., 2007). There was evidence that mass communication methods delivered as stand-alone activities or as one component of a communication mix can improve uptake in target populations. While there was some evidence that the use of personalized communication interventions, particularly face-to-face outreach to individuals who have not responded to routine opportunities also improves uptake, the SLR did not identify any compelling evidence that personalized methods were effective at scale. In view of the low levels of seasonal influenza vaccine uptake among HCWs in many European countries, targeting HCWs might be a particularly effective policy in order to reduce risk in vulnerable settings such as health care facilities. The evidence suggests all forms of promotional communications have the potential to stimulate



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HCW vaccine uptake and that promotional communications that target HCWs can also improve uptake among patients. Education and training of HCWs was a popular intervention approach and a number of studies reported positive outcomes. Enhanced convenience and accessibility of immunization was also associated with improved vaccination uptake among HCWs. There are clearly logistical benefits for the service provider, staff, and resident patients if improved access to vaccination can be provided in health care settings. Immunization coverage at the population level is essential if public health objectives and benefits are to be fully realized, and for this to occur, there must be population-level acceptance and support for nationally recommended immunization schedules (Shetty, 2010). Promotional communications are only one of the many factors that can influence public attitudes toward vaccination. Information—and misinformation—about immunization is readily available in broadcast media and online, and negative discourse and commentary has been identified as a causal factor in vaccine hesitancy (Opel, Diekema, Lee, & Marcuse, 2009). Lack of public confidence in health systems and institutions recommending vaccination and lack of awareness about the possible serious consequences of infection has also been identified as a cause of less than optimal vaccination coverage (Opel et al., 2009). Effective promotional communications should take these, and other influencing factors, into account. The SLR did not identify the use of, or reference to, any macro-level theories for behavior change, or research on how promotional communication might improve large scale public acceptance. There was some evidence for the positive influence of advocacy efforts and initiatives intended to foster a pro-vaccination culture in targeted settings (e.g., see Llupia et al., 2010), but overall little focus on what, why, and how social and cultural norms and trends might influence vaccine behaviors among populations. Understanding and measuring social influences, on what is ultimately an individual behavior choice, is challenging but perhaps needs to be a future priority. Poorly conceived and executed communications might not only be wasteful of resources, but might exacerbate latent mistrust and anxieties (Abraham, 2009; Rimer & Kreuter, 2006). Conclusions Promotional communications can boost seasonal influenza vaccine uptake. The current evidence base for effective practice is fragmented and incomplete, but it clearly indicates that a range of promotional communications can improve uptake. Future development of evidence-based good practice could be enhanced by more detailed reporting and evaluation of intervention components, the rationale for their inclusion and their individual contribution to overall effect size. A current priority for policy is improving public acceptance of influenza vaccination (Shetty, 2010). To achieve this, a shift in focus from communications primarily or exclusively targeting intrapersonal and psychological factors to more support for strategy and interventions aimed at interpersonal and sociocultural behavioral determinants of vaccine acceptance is recommended.

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*Arthur, A. J., Matthews, R. J., Jagger, C., Clarke, M., Hipkin, A., Bennison, D. P. (2002). Improving uptake of influenza vaccination among older people: A randomized controlled trial. British Journal of General Practice, 52, 717–718, 720. Burls, A., Jordan, R., Barton, P., Olowokure, B., Wake, B., Albon, E., & Hawker, J. (2006). Vaccinating healthcare workers against influenza to protect the vulnerable—Is it a good use of healthcare resources? A systematic review of the evidence and an economic analysis. Vaccine, 24, 4212–4221. Cairns, G., MacDonald, L., Angus, K., Walker, L., Cairns-Haylor, T., & Bowdler, T. (2012). Systematic literature review of the evidence for effective national immunisation schedule promotional communications. Stockholm, Sweden: ECDC. *Chanel, C., Staphane, L., Massoni, S. A., Vergnaud, J.-C. (2011). Impact of information on intentions to vaccinate in a potential epidemic: Swine-origin influenza A (H1N1). Social Science & Medicine, 2, 142–148. Crowe, M., & Sheppard, L. (2011). A review of critical appraisal tools show they lack rigor: Alternative tool structure is proposed. Journal of Clinical Epidemiology, 64, 79–89. *de Juanes, J. R., García de Codes, A., Arrazola, M. P., Jaén, F., Sanz, M. I., & González, A. (2007). Influenza vaccination coverage among hospital personnel over three consecutive vaccination campaigns (2001–2002 to 2003–2004). Vaccine, 25(1), 201–204. *Dey. P., Halder, S., Collins, S., Benons, L., & Woodman, C. (2001). Promoting uptake of influenza vaccination among health care workers: A randomized controlled trial. Journal of Public Health Medicine, 4, 346–348. Glynn, L. (2006). A critical appraisal tool for library and information research. Library Hi Tech, 24, 387–399. *Hak, E., Hermens, R. P., Hoes, A. W., Verheij, T. J., Kuyvenhoven, M. M., & van Essen, G. A. (2000). Effectiveness of a co-ordinated nation-wide programme to improve influenza immunisation rates in The Netherlands. Scandinavian Journal of Primary Health Care, 18, 237–241. *Hull, S., Hagdrup, N., Hart, B., Griffiths, C., & Hennessy, E. (2002). Boosting uptake of influenza immunisation: A randomised controlled trial of telephone appointing in general practice. British Journal of General Practice, 482, 712–716. *Humair, J.-P., Buchs, C. R., & Hans, S. (2002). Promoting influenza vaccination of elderly patients in primary care. Family Practice, 4, 383–389. Jefferson, T., Rivetti, D., Rivetti, A., Rudin, M., Di Pietrantonj, C., & Demicheli, V. (2005). Efficacy and effectiveness of influenza vaccines in elderly people: A systematic review. Lancet, 366, 1165–1174. *Llupia, A., Garcia-Basteiro, A. L., Olivé, V., Costas, L., Rios, J., Quesada, S., … Trilla, A. (2010). New interventions to increase influenza vaccination rates in health care workers. American Journal of Infection Control, 6, 476–481. *Looijmans-van den Akker, I., van Delden, J. J. M., Verheij, Th. J. M., van der Sande, M.A.B., van Essen, G. A., Riphagen-Dalhuisen, M. E., … Hak, E. (2010). Effects of a multi-faceted program to increase influenza vaccine uptake among health care workers in nursing homes: A cluster randomised controlled trial. Vaccine, 28(31), 5086–5092. *Luthi, J.-C., Méan, F., Ammon, C., & Burnand, B. (2002). Evaluation of a population-based prevention program against influenza among Swiss elderly people. Swiss Medical Weekly, 1, 592–597. *Malmvall, B. E., Franzen, I., Abom, P. E., & Hugosson, M. B. (2007). The rate of influenza immunization to people aged 65 years and older was increased from 45% to 70% by a primary health care-based multiprofessional approach. Quality Management in Health Care, 1, 51–59. *Maltezou, H. C., Maragos, A., Halharapi, T., Karagiannis, I., Karageorgou, K., Remoudaki, H., … Pierroutsakos, I. N. (2007). Factors influencing influenza vaccination rates among healthcare workers in Greek hospitals. Journal of Hospital Infection, 66(2), 156–159. Mereckiene, J., Cotter, S., D’Ancona, F., Giambi, C., Nicoll, A., Lévy-Bruhl, D., … O’Flanagan, D. (2010, November 4). Differences in national influenza vaccination policies across the European Union, Norway and Iceland 2008–2009. Eurosurveillance, 15(44).



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