Veterans Affairs Medical Center employee comments suggest additional educational targets to improve influenza vaccination campaigns

The Veterans Health Administration strongly encourages all employees to receive an annual influenza vaccine with the goal of achieving a 90% vaccination rate among healthcare personnel (HCP) by 2020 [1]. A nationwide survey conducted by Schult et al. queried reasons that Veterans Affairs employees did not get the 2009–2010 influenza vaccine, offering 12 specific reasons for declining the vaccine [2]. Interactions with employees at two Veterans Affairs Medical Centers (VAMCs) raised the possibility of a wider array of reasons for vaccine refusal. We surveyed employees at both VAMCs regarding their reasons for accepting or declining the influenza vaccine in the 2013–2014 season, including the option to explain their views using comments entered as free text.

The Institutional Review Board at both participating facilities reviewed and approved the survey and study design. Employees at two VAMCs were invited via e-mail to participate in an anonymous, voluntary survey accessed through an internet link that took <5 minutes to complete (Qualtrics, Provo, UT). The survey included questions similar to those previously described with the addition of free-text options for respondents to further explain their views [2,3]. Each of the authors independently reviewed the free-text responses and grouped them into themes. Some respondents offered comments that fit more than one theme.

Out of 498 respondents, 477 (96%) completed the survey. Among these, 363/477 (76%) reported receiving the 2013–14 influenza vaccine. Respondents indicated the following reasons for getting a seasonal influenza vaccine: protect self (91%), protect friends and family (82%), availability of vaccine without cost (65%), protect patients (57%), previously had “the flu” (27%), healthcare provider recommendation (21%), mandatory requirement at a non-VHA workplace (8%), and other (6%). Respondents indicated the following reasons for not getting an influenza vaccine: other (53%), concerned about side effects (37%), gives me “the flu” (17%), not needed (11%), does not work (11%), allergy (9%), do not like shots (8%), healthcare provider recommendation (6%), sick when the vaccine was offered (4%), forgot (4%), no time (4%), attempted but not able (1%) and did not know I needed it (0%).

Among those who indicated they received the vaccination, 95 individuals (26%) offered a total of 105 comments in the free text portions of the survey. We examined the themes from these comments, finding that 31 respondents had suggestions on improving access or acceptance of the vaccine, 17 indicated convenience was part of the reason they took the vaccine, 13 indicated they take the vaccine every year and 4 reported they still got sick with influenza.

Among those who did not receive the vaccine, 65 individuals (57%) made a total of 82 comments in the free text portions of the survey. Despite having 12 familiar rationales to choose from, most non-vaccinated respondents included “other” as a reason for refusing vaccination. While many of the comments expanded on the 12 rationales offered, 41 comments (50%) offered reasons not already included in the survey. We examined the themes from these comments, finding that 18 respondents cited alternative protection strategies for influenza prevention, 13 offered a quasi-scientific rationale, 10 expressed mistrust of the government and pharmaceutical industry while 9 indicated concern related to vaccine components (Table 1).

Table 1.

Examples of comments from respondents who reported not getting the influenza vaccine, organized by theme

Theme	Examples of Respondent Commentsa
Alternative protection strategies	I keep my immune system up by eating healthy and exercising. I am young and healthy and would rather develop natural immunity than be vaccinated. Using a lot of probiotics I have not been sick in over a year.
Quasi-scientific rationale	I am pregnant. It is not the current strain of the flu. I don’t believe the effectiveness of the vaccine outweighs the risks.
Mistrust of government, pharmaceutical industry	Someone is getting kickbacks for pushing the flu shot so much. Stay out of my healthcare, Government! CDC vaccination board members are paid consultants to pharmaceutical companies. They have vested interest in vaccines, not in health and well-being of people.
Vaccine component concerns	I don’t like thimerosol in the flu shot or other ingredients. We live in world full of genetically engineered products therefore I prefer not to place foreign substances in my body. I do not want to put unknown chemicals in my body.

^aSome comments have been edited for length or clarity.

While results from the multiple-choice portion of our survey were similar to previous reports, analysis of free-text comments revealed rationales not included on similar surveys [2,3]. Addressing these rationales may suggest strategies to improve influenza vaccination rates among HCP. The CDC found influenza vaccination rates among HCP are highest in settings where the vaccination is required [4]. Absent a mandatory requirement, targeted education remains the principal strategy to increase influenza vaccination rates. Concerns raised by our survey respondents suggest additional themes to incorporate into educational campaigns. To allay concerns about ingredients or chemicals, highlighting the use of thimerosol-free vaccine may increase acceptance. Additional information about the economic benefits of influenza vaccination extending to reducing healthcare costs may help offer a positive interpretation of possible financial motivations. Details about the potential for someone with mild symptoms to transmit influenza to less fortunate people who lack a robust immune system might appeal to individuals who believe their personal immune system can withstand an influenza infection. This could be supported by a theme of altruism, asserting that HCP have an ethical and moral responsibility to protect their patients from influenza. Finally, frank acknowledgement that the influenza vaccine is not always effective may increase the trust towards the campaign as a whole. This message should be closely coupled with an explanation that the protection conferred from this year’s vaccine may help offer personal immunity towards future influenza strains as well as decrease mortality among patients [5,6,7].

Our study has some limitations. Based on the approximate numbers of total employees, we estimate a low response rate (14% at Facility A; 5% at Facility B). Additionally, the survey was sent to all employees at the medical centers rather than only to those with direct patient contact. Furthermore, VAMC employees who refused the vaccine due to strong internal beliefs (i.e. concerns about government/pharmaceutical industry) may have been more likely to participate in our survey, compared to those with less emotionally charged reasons (i.e. forgot or sick when offered), creating a bias towards those with grievances about the vaccine. Nonetheless, given than 50% of our respondents chose “other” as a reason for declination, we suggest future surveys should consider a design that takes into account candid comments from HCP.