cs c,
b
it, Liver
tingham
fResearch Design Service for the East Midlands, School
gHealth Protection Agency East Midlands, Nottingham C
a r t i c l e i n f o
influenza outbreaks in closed institutions.4 In the UK, it is recom-
mended that National Health Service and social care employers
should offer influenza vaccination to employees directly involved in
patient care, including those in care homes, with responsibility for
vaccination resting with the employer.7 In addition, since 2005,
to be low,1,9,10 with awareness and understanding of influenza and
influenza vaccine also low in this group.9
The principal aim of this study was to establish the uptake of
influenza vaccine amongst care home staff with a direct health or
caring role in Greater Nottingham care homes with nursing. In
addition, in order to establish what could be done to improve
vaccine uptake in this group, the particiapnts we asked about their
knowledge, attitudes and beliefs associated with vaccine uptake.
* Corresponding author. Tel.: þ44 1245 398732; fax: þ44 1245 398711.
Contents lists availab
H
evi
Public Health 123 (2009) 645–649E-mail address: amir.shroufi@doctors.org.uk (A. Shroufi).Conclusions: All care homes for the elderly should have a vaccination policy which recommends staff
vaccination. Educational campaigns, vaccination in the workplace and free provision of the influenza
vaccine may help to improve vaccine uptake in this group.
 2009 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction
Care workers in care homes have an increased risk of con-
tracting influenza and, once infected, have the potential to spread
disease to care home residents.1,2 Vaccination of healthcare
workers has been shown to reduce absenteeism, disease spread
and patient mortality in residents.3–6 Furthermore, staff vaccina-
tion is important in generating herd immunity and reducing
main carers for the elderly and disabled have been recommended
to receive the vaccine.8
In the USA, the Advisory Committee on Immunisation Practices
has recommended that all healthcare workers in contact with
high-risk patients should receive the influenza vaccine, and a goal
of 60% vaccine uptake has been set for this group.1,4 Despite such
recommendations and supporting evidence, previous studies on
influenza vaccine uptake among healthcare workers have shown itArticle history:
Received 5 January 2009
Received in revised form
13 July 2009
Accepted 22 September 2009
Available online 28 October 2009
Keywords:
Immunization
Influenza
Care homes
Vaccination
Nursing homes0033-3506/$ – see front matter  2009 The Royal So
doi:10.1016/j.puhe.2009.09.014of Community Health Sciences, University Park, Nottingham, UK
ity Hospital, Nottingham, UK
s u m m a r y
Objectives: To establish uptake of influenza vaccine amongst care home clinical staff in Greater
Nottingham, and to investigate what could be done to improve vaccine uptake in this group.
Study design: Postal questionnaire surveys were used. In the first instance, a total sample survey was
used. In the second instance, a sample of care home staff was surveyed, randomized at the care home
level.
Methods: A postal questionnaire completed by care home matrons was used to obtain a preliminary
estimate of staff vaccine uptake. Individual staff questionnaires were then used to validate this finding,
and measure attitudes, beliefs and behaviours associated with vaccination.
Results: Vaccine uptake among those working in care homes with nursing was found to be low. Vaccine
uptake was higher in homes with a policy recommending vaccination of staff. Most respondents who had
received vaccination reported that they had done so because of an existing medical condition, rather
than because of being a healthcare worker. A statistically significant relationship (P¼ 0.02) was found
between individuals’ reported beliefs on how well they could resist influenza and their vaccination
status.dCheshire and Merseyside Health Protection Un
eOncology Unit, Nottingham City Hospital, Notpool, UK
, UKNHS Nottingham City, Nottingham, UK
c School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, UKOriginal Research
Influenza vaccine uptake among staff in
A random cluster sample survey
A. Shroufi a,*, J. Copping b, P. Musonda c, R. Vivanco
aNHS Mid Essex, Swift House, Chelmsford CM2 5PF, UK
Public
journal homepage: www.elsciety for Public Health. Publishedare homes in Nottinghamshire:
d, V. Langden e, S. Armstrong f, R. Slack g
le at ScienceDirect
ealth
erheal th.com/journals /pubhby Elsevier Ltd. All rights reserved.

status, and therefore could not be used in the estimation of the
influenza vaccine uptake rate in staff.
In the validation survey, 169 completed questionnaires were
obtained from 219 staff approached by the research assistant,
giving a 77% response rate. Not all of these respondents provided
a response to all questions. Of the 169 respondents, 122 were care
assistants, 35 were registered nurses and 12 were matrons.
Vaccine uptake
The uptake of influenza vaccine among staff was reported to be
20% in care homes responding to the initial questionnaire. In the
validation survey, only 29 of 169 respondents claimed to have been
vaccinated against seasonal influenza in the present season,
suggesting an uptake of 17% (95% CI 11–23%).
Characteristics of care homes and respondents associated with staff
vaccine uptake
Forty-eight care homes responded to the question about
whether they had a policy on staff influenza immunization; 10%
HealMethods
Vaccine uptake
The aim of this part of the study was to obtain an initial estimate
of influenza vaccine uptake. In January 2006, a self-completed
questionnaire was sent to head nurses (matrons) of care homes
registered for nursing care within Greater Nottingham. People
completing the questionnaires were asked to note how many staff
were on duty at that time, and to establish how many of them had
received the influenza vaccine during the current season. This
approach was used to avoid some of the difficulties posed by large
staff registers comprising many part-time staff, whose vaccination
status would likely be difficult to establish. Information on the care
home’s policy towards staff influenza vaccination was also
collected. A cover letter and freepost envelope were included. Non-
respondents were followed up in the first instance with a reminder
letter, followed by up to three reminder phone calls.
In order to validate the result obtained, a second survey was
undertaken. A random sample of 24 care homes was selected to be
surveyed by placing all care homes in the area on a database.
Random allocation was then used to select those that would be
visited in collecting the sample. Each care home was visited by the
same research assistant. Each member of staff who was on duty at
the time of the research assistant’s visit was asked to complete
a questionnaire, and completed questionnaires were collected by
the research assistant during the same visit. The number of staff
unable to, or not wishing to, complete a questionnaire was recor-
ded. Confidentiality was emphasized to staff, and all completed
questionnaires were placed in an unmarked envelope which was
then sealed. This process was carried out until an adequate number
of questionnaires had been collected. Questionnaires were scanned
electronically and read into a database.
Beliefs and behaviours associated with vaccine uptake
Questions were asked to gauge staff beliefs about influenza
vaccine which may encourage or discourage them from being
vaccinated. Questions investigated perceived vaccine efficiency, the
individual’s perceptions of their susceptibility to influenza, and
their workplace policy on vaccination.
In order to judge the appropriateness of staff illness behaviour,
staff were asked whether they agreed or disagreed with the
statement that they would still come to work if they thought they
had influenza.
Staff perceptions on measures which would encourage increased
vaccine uptake
In order to guide attempts to improve vaccine uptake in this
group, staff were asked what would encourage them to be vacci-
nated against influenza in future; seven options were provided
(Table 1). Staff were also asked if encouragement from their general
practitioner, matron or colleagues would make them more likely to
receive the vaccine next season. More than one response could be
selected to each of these questions.
Not all questions were completed within each questionnaire, so
the results have been calculated on the appropriate denominators.
Statistical methods
Based on the results of the first part of the study, it was antici-
pated that uptake of the influenza vaccine would be in the range of
16–24%. The midpoint of this range was taken as the basis for the
A. Shroufi et al. / Public646sample size calculation for the validation survey. In order toestimate an expected uptake of 20% with a two-sided 95% confi-
dence interval (CI) ranging from14.5% to 25.5%, a sample size of 200
individuals was required. Although the study also aimed to explore
associations between knowledge or behaviours and vaccine uptake,
the study was not specifically powered for this purpose as this was
a secondary aim.
Descriptive statistics were carried out using Statistical Package
for the Social Sciences version 15 (SPSS Inc., Chicago, IL, USA), and
other measures of associations and logistic regression were
conducted using STATA statistical software version 10.0 SE (Stata
Corporation, TX, USA), using survey commands to account for the
sampling design of the survey. This was done using sampling
weights (P-weights), being the inverse of the probability of an
individual in each care home being included in the study.
Results
Questionnaires were sent to 62 care homes, but it was later
found that four of these had closed. Of the remaining 58 care
homes, 52 responded, representing a 90% response rate. However,
nine care homes did not provide information on staff vaccination
Table 1
Staff opinions on measures which would make them more likely to receive the
influenza vaccine next season.
Agree
(%)
Disagree
(%)
P-value
(exact)
% Difference
(95% CI)
Being told that it is free
for carers of the elderly
63 (37%) 106 (63%) 0.0009 26% (41%, 10%)
Being provided with
vaccine in the
workplace
90 (53%) 79 (47%) 0.399 6% (8%, 22%)
More information about
the influenza vaccine
54 (32%) 115 (68%) <0.00001 36% (51%, 21%)
Encouragement from
manager/matron
38 (22%) 131 (78%) <0.00001 56% (70%, 40%)
Encouragement from
general practitioner
or practice nurse
72 (43%) 97 (57%) 0.055 14% (30%, 0%)
Hearing about it on
television or radio
20 (12%) 149 (88%) <0.00001 76% (91%, 61%)
Encouragement from
colleagues
24 (14%) 145 (86%) <0.00001 72% (87%, 57%)
CI, confidence interval.
th 123 (2009) 645–649(5/48) of care homes had such a policy. Among care homes without