Boost compliance rates by addressing HCW concerns

Flu vaccination rates rise after surveying workers

Identifying the concerns of employees who did not participate in an influenza immunization program increased vaccination rates by more than 50% at Children’s Hospital in New Orleans.1

Approximately 66% of the institution’s 1,100 employees have direct patient contact, yet only 21% of health care workers received vaccine in the 1995-1996 flu vaccine season. That percentage is typical of other hospitals too, says Rodolfo E. Begue, MD, director of infectious diseases at Children’s.

Each year, educational programs had been provided to increase workers’ awareness of the disease and explain the need for vaccination. Reminder letters were mailed to all employees, notices were posted in common areas, and vaccination carts were taken to nursing units and other work locations. Nevertheless, compliance rates remained low. That prompted the infection control department to conduct a survey evaluating HCWs’ attitudes and behaviors concerning influenza immunization, with the goal of identifying ways to boost compliance.

Anonymous questionnaires were mailed to a randomly selected sample of personnel, 100 of whom had been vaccinated during the previous season and 100 of whom had not. The survey yielded some surprising results and provided new ways of persuading employees to be vaccinated.

"Going to employees and asking them what they feel is important is a new approach, and once we got that information, we went back with the next [immunization] campaign and addressed their specific issues," Begue says. "What we as managers believe is important is different from what workers might feel is important."

For example, the researchers found that 78% of workers who had received vaccine did so out of concern for their personal health. Only 18% indicated that concern for hospitalized patients’ health was their motivation.

"To them it’s important not to miss workdays so they don’t have to take vacation time in the winter that they would like to use in the summer," Begue explains. "Some things that managers don’t think of are really the key points that can turn things around. It’s not that workers don’t care about patients’ health, but it’s not their first priority. Unless you talk in their language, they’re not going to get the point the way you want them to. When you start to talk about them not having to take any time off due to being sick and not having to lose any money, that makes more sense to them than theoretical issues such as patients’ health and infection control."

Researchers also found that the main reason for nonacceptance of vaccine was concern about influenza infection. But the survey also showed that influenza-like symptoms (cough, fever, and myalgias) were reported similarly during the winter for both vaccinated and unvaccinated employees. However, unvaccinated workers missed nearly twice as many days of work.

Begue says vaccinated workers who experience systemic symptoms during the winter either are ill from other viruses that circulate during that time, or they have a much milder form of the flu.

Other top reasons for accepting vaccine, according to the survey, were the convenience of vaccine administration, the no-cost vaccine offered to employees, and the receipt of vaccine in previous years. Other reasons found for nonacceptance of vaccine included not feeling at risk for influenza infection and concern about a severe reaction.

For the following vaccination season, Begue and staff addressed specific HCW concerns as indicated on the survey as well as providing routine information about the vaccine. Vaccination compliance improved for workers both with and without direct patient contact, as well as for medical staff members, with an overall participation rate of 38%.

Pregnant workers are a problematic group, Begue says, because in many cases their obstetricians tell them not to be vaccinated. "I’m afraid some obstetricians don’t have the right information. They always tell [pregnant women] not to get the vaccine, but actually they should be getting it. We must talk with our friends in OB/GYN and tell them that pregnant women actually should get vaccinated," he says.

Successful vaccination programs also require administrative leadership, he adds. "You as a physician or as a nurse talking to employees alone is probably not enough. Administrators must be involved and communicate to workers that unless they have a good reason not to get it, they must get this vaccine. They don’t have to make it mandatory, but somehow they have to convey the message that this is a good thing for workers to do for themselves and for the institution," he says.

Begue notes that most of the opposition to getting vaccinated at his facility has been from physicians.

"We’re supposed to know all this, but our response can be very primitive," he says. "We all get like children when confronted with needles, so we need to do a lot of coaching starting from medical school. Education is the answer, but we still have a long way to go."


1. Begue RE, Gee SQ. Improving influenza immunization among health care workers. Infect Control Hosp Epidemiol 1998; 19:518-520.