We describe a successful campaign to improve vaccination against seasonal influenza for HCWs at our health service. Our immunisation program was implemented with only a small increase in resourcing, used to increase vaccine availability as well as developing a social marketing campaign and database support for timely reporting throughout the program.
We identified several enablers and barriers to vaccination in the survey that are similar to those previously described [11,12]. Messages to encourage vaccination should focus on protection against influenza for staff, their families and their patients. Barriers to vaccination, particularly the perception that immunisation does not work, that staff may not be at risk of influenza and adverse effects of immunisation, should be addressed [6]. Although our survey was limited by a low response rate, our findings are similar to those reported elsewhere [13,14]. Our findings also suggested that a significant minority of staff opted for vaccination elsewhere, an important issue to consider where a large proportion of the workforce is employed on a part-time basis.
Despite the limitations, these findings were useful in formulating a promotional strategy to improve influenza vaccine uptake. The application of social marketing principals to healthcare is a useful framework to consider promotional measures to support public health strategies [15]. Our program focused on the “marketing mix” of price (provided free, and addressing perceived barriers), promotion (strategic use of incentives, regular communication and feedback), placement (mass immunisation days supplemented by ward-based services) and product (emphasizing the benefits of vaccination) [16]. A feature of our infection prevention activities is the strong support of senior hospital executive and senior medical staff. This is reflected by high uptake of influenza vaccination amongst medical staff (87.1%) and also other process measures such as compliance with hand hygiene practices (medical staff 81.6%, nursing staff 76.6% compliance in 2014). The staff influenza vaccination campaign forms part of a broader effort to improve patient safety at our health service by preventing infections in staff and patients.
The proportion of staff vaccinated in our health service following this campaign (80.3%) was much higher than we had previously achieved, and higher than other published figures in Australian hospitals [17,18]. In a review of 10 Australian studies, only 3 studies documented vaccination rates of more than 50% [19], with 2 associated with the implementation of active policies or campaigns. Barriers to vaccination included the lack of free vaccine and poor convenience of vaccination services [19]. Reasons for staff non-compliance with our dedicated program were not assessed as part of the current study, but we believe this to be an important consideration in planning of future programs. Our program coincided with a statewide target of 75% vaccine uptake by HCWs being set by the Victorian Department of Health in 2014,[18] and this being introduced as a key performance indicator for Victorian hospitals [20].
Though successful in achieving improved vaccination uptake, our dedicated program did not result in uptake comparable to a recent non-mandatory program implemented at a Japanese centre [7]. This strategy achieved a 97% vaccination uptake, but was implemented at a smaller single-site hospital and included interviewing of non-compliant staff by hospital executive. Our program spanned larger and multiple hospital campuses, and did not involve direct liaison of hospital executive with employees, and this may explain the observed differences in vaccine uptake.
Mandatory vaccination policies [21] are recommended by the Centers for Disease Control and Prevention for hospitals in the United States. While we strongly support the use of influenza vaccination to protect staff and patients, we have previously outlined reasons why we do not believe a mandatory vaccination policy is justified for influenza [22]. These include the moderate effectiveness of the vaccine [23], the lack of data suggesting that nosocomial transmission is a significant problem [24], and the availability of alternative, less restrictive policies to achieve the same goals. Additionally, mandatory influenza vaccination policies present new challenges, including the need for staff redeployment or the wearing of masks [25]. A survey of healthcare workers in two NSW hospitals demonstrated poor support for mandatory policies for influenza vaccination [26], and this has also been voiced more broadly by national stakeholders involved in vaccination policy or program implementation [27].
In summary, we have developed and implemented a successful campaign to improve influenza vaccine uptake at a large Australian healthcare facility. This campaign was informed by a staff survey, and included social marketing, feedback to managers and improving the availability of vaccination. Use of comparable strategies in other centres without mandatory programs would potentially increase vaccine uptake.
