Notification about seasonal influenza vaccination: what is the best way to increase uptake?

Each year, countries undertake public health campaigns to encourage their population to have the seasonal influenza vaccine in an effort to reduce the number of people who will suffer from influenza and influenza-related complications. Influenza vaccines are generally considered to be safe, and are effective in reducing hospital admissions, complications and mortality in at-risk patients.¹ Ensuring that patients are aware of the availability of the vaccine and are able to make an informed choice about whether to be vaccinated is an important responsibility for primary care physicians. Although the generally poor uptake of seasonal influenza vaccination is well-recognised around the world,^1,2 the issue is particularly topical now given the disappointing uptake of vaccines during the recent H1N1 influenza pandemic.³

In this issue of the PCRJ, Van Rossem et al.⁴ report findings of an investigation into whether patients of family practices in Belgium want to be notified about the availability of the influenza vaccine. Approximately 80% of the total study population reported wanting to be notified, a fact which Van Rossem et al.⁴ rightly note should encourage us to be proactive in inviting patients to be vaccinated. Yet around 20% of patients did not wish to be notified. This figure increased to 34% among those who had never previously been vaccinated. The authors suggest that this reflects the fact that “some people have already made up their mind about their refusal to be vaccinated” implying that “subjects who had never been vaccinated” had “less need [sic] for notification.”

But are we right to assume that such patients have truly exercised informed choice, or do these patients actually have more, not less, need for information and advice? Studies investigating the reasons why some eligible patients do not receive the vaccine have identified a number of important risk factors, many of which do not sit well with our scientific understanding of the risks and benefits of the vaccine. These reasons range from lack of awareness that the vaccine is available and confusion as to who qualifies to receive it,^5,6 through to perceptions that influenza is not a particularly serious illness, that the vaccine causes influenza, or that the vaccine is likely to cause long-term health effects.⁷ Regardless of personal desires about influenza vaccination notification, it remains the responsibility of health care professionals to ensure that members of the public — particularly those who fall into a risk category — are provided with adequate information about the availability of the vaccine and about the true risks and benefits involved in having it. A proactive notification strategy, as advocated by Van Rossem et al.⁴, is to be applauded — though notification combined with information that specifically targets those misunderstandings or barriers that prevent people from receiving the vaccination may be even better.

Targeting particular vaccination misunderstandings can be a difficult task, and recent research shows that simplistic attempts to correct misconceptions via leaflets could potentially do more harm than good.⁸ Fortunately, Van Rossem et al.⁴ have also highlighted a better way of delivering this information by demonstrating the important role that the family physician plays with regards to the uptake of influenza vaccination.⁴ Among those who wanted to be notified of vaccination opportunities in their study, 85% reported that they wanted to be notified by their family physician, mostly during a regular consultation. Preference for this is supported by research that shows a significant increase in levels of vaccination following a personal invitation or recommendation from a family physician.^5,9 But while a face-to-face discussion with a trusted healthcare worker may be the best way of encouraging patients to accept vaccination, we must be mindful that healthcare workers themselves are notoriously bad when it comes to having their seasonal flu vaccination. Within the UK, uptake of the vaccine by healthcare workers languishes at about 37%.¹⁰ A study by our team investigated the reasons given by healthcare workers for not having the pandemic or seasonal influenza vaccine and found that they were more likely than the general public to cite a belief that the vaccine is dangerous, has side effects or is ineffective. Relying on healthcare workers to communicate about the benefits of a vaccination that they themselves are unwilling to have may be less effective than we might hope.

The study by Van Rossem et al.⁴ has contributed valuable information about the popularity of influenza vaccine notification and preferred notification methods. Evidence-based methods for increasing the impact of this notification should now be a priority. Based on this and existing research it appears that there is a need to produce and disseminate clearer messages to both the general public and healthcare workers about the benefits of the vaccine, the risk of side effects, and who is eligible to be vaccinated.