Using qualitative methods, this study explored the occupational influenza vaccination policies and practices currently in place in public hospitals in three states of Australia. In every interview, the central issue participants highlighted was the enormity of the task of promoting and delivering the vaccine annually, sometimes in an environment with extremely low staff support. The difficulty in procuring any resources or funding or extra staff members was also mentioned, and was perceived to affect the ability to sufficiently promote and deliver the vaccine to increase compliance rates. In some instances, participants were responsible for overseeing the delivery of the influenza vaccine to staff over a large number of sites (19 in one instance), or sites that are located in different parts of a city (separated by 50 km or more). Last, many sites did not have the capacity to properly document and maintain databases and track coverage.
The need to continually promote the importance of getting the influenza vaccine at every possible opportunity was a common theme in our study. Most sites employed multiple strategies to educate staff about the importance of getting vaccinated and to deliver the vaccine to staff. Mobile carts, out of hours clinics, and peer-to-peer vaccination were just some of the methods recounted.
Non-mandatory campaigns using these measures have previously been shown to be successful at increasing influenza vaccination among HCWs
[16–18]. For example, Quan et al. reported an increase of 20% in the vaccination rate after the introduction of a program of strategies that included decentralised vaccine distribution, the use of mandatory declination forms, and the use of mobile carts to provide vaccines at routinely scheduled physician and medical staff meetings and directly to clinical units. While this pushed the vaccine coverage at the hospital to 62.9%, cumulative campaigns using these strategies did not result in any further changes to the rate
. In closing, the authors highlighted that even though the campaign significantly improved vaccination levels beyond the national norm, a mandatory vaccination policy was needed to reach vaccination levels in excess of 90%
The use of incentives was common factor among the interviews. In most instances, the incentives were merely a lollipop that had been provided by the vaccine manufacturer. On some occasions, raffles or competitions had been used to encourage staff to get vaccinated. In these cases, sites had to use their own budgets or rely on gifts from other members of the hospital community to use as prizes, and hence were not able to maintain the practice. In 2005, Kimura et al. reported on the interventions used to increase influenza vaccination of HCWs in California and Minnesota
. After the introduction of an incentive (a movie ticket or books on health or medical topics), the site recorded a 13.8% increase in uptake among its employees. However, it is difficult to quantify the impact of the introduction of the incentive in this setting, as a range of other strategies was already in place at the sites.
While there are mixed reports about the impact of incentives on occupational vaccination, in other areas of employee health and safety the evidence is strong that incentives and rewards work better than punishments
. From our interviews, incentive giving appears to be an approach that participants feel is important to continue. Given the problems associated with providing each vaccinated staff member with an individual incentive, institutions may want to consider the use of public recognition for HCWs who choose to accept influenza immunization. For example, there could be honourable mentions or rewards for hospital units or wards whose staff vaccination rate reached a set percentage
While the use of “opt out” declination forms was reported by a number of our respondents, most found the practice resource intensive and problematic, and had abandoned using them. The intent of a declination statement is to ensure that HCWs are appropriately informed of the rationale for influenza vaccination, to promote the message of patient safety, and to dispel commonly held misconceptions about influenza and influenza vaccination. The major benefit associated with using these forms is that, unlike the introduction of mandatory vaccination policies, they allow HCWs to retain their autonomy and their right to refuse treatment: they can simply choose to opt out if they do not wish to be vaccinated. However, to date most studies have failed to show any real or substantial benefit associated with their use
What has been established is that the use of declination forms is associated with increased resources to track compliance (as noted by a number of our participants), the risk of negatively affecting the employer–employee relationship, and the need for institutions to determine the punitive consequences for HCWs who refuse to sign the document. In the concluding statement of a recent review examining the use and impact of declination statements the authors emphasised that there may be increases in vaccination coverage, and a decrease in staff misconceptions about the influenza vaccine, if the declination statements were bundled with other measures that emphasised the rationale for and importance of vaccination, and decreased barriers to receipt of the vaccine
The difficulty in maintaining databases and tracking staff vaccination was often highlighted during the interviews. Some sites did not have the capacity to follow up with staff members who were vaccinated off-site, whiles others did not keep records for non-payroll hospital workers (volunteers, ancillary staff, and agency staff). At the extreme, some sites relied on hard copy consent forms as evidence of staff vaccination because they did not have the capacity to enter the information into a computerised system. As a result of this, participants spoke of the frustration of not being able to appropriately target areas with low uptake with resources and/or education.
Previous studies have recognised the benefits associated with the ability to build computer programs to calculate vaccination rates. These include: (1) easy identification of noncompliant staff members and the provision of information back to ward managers, (2) calculation of and feedback about rates throughout the influenza season, and (3) mobilising of resources or interventions to target groups within the hospital that continue to have low levels of uptake
. If healthcare institutions adopt a method for monitoring and reporting on influenza vaccination rates, fair and uniform comparisons of these rates across institutions could also be possible.
When respondents were asked whether their hospital and staff would support a mandatory influenza vaccination policy, a mixed response was received. It was felt that institutions would not independently introduce a policy, and that currently there was no support for it among staff. The perceived lack of support for a mandatory influenza vaccination policy correlates well with the findings from a survey of Australian HCWs
, which reported that less than 50% of staff supported the inclusion of the influenza vaccine into a national policy. Participants did, however, acknowledge that a mandatory policy would be acceptable if it was executed by the state health department or if it included consequences for non-compliance (i.e. a policy of mask use or relocation). Further studies need to be conducted to explore the need for and use of mandatory policies in an Australian setting.
The high response rate and the use of in-depth interviews to elicit a greater depth in the information are two key strengths of the present study. Limitations include that (1) member checking of themes was not undertaken; and (2) interviews were only undertaken with a select group of hospital staff, so the possibility of other important themes emerging cannot be ruled out. Specific details regarding the participants’ role at the hospital was also not included. This was a small, qualitative study, and the findings should be explored further in larger, quantitative studies.