Chris Ferris, MA University of Texas School of Public Health April 14, 2011

1. USE OF INTRANET AND OTHER INTERVENTIONS TO INCREASE INFLUENZA VACCINATION AMONG HEALTH CARE WORKERS Chris Ferris, MA University of Texas School of Public Health April 14, 2011

2. Influenza (the Flu) • Serious respiratory illness • Epidemics occur annually • 3-5 million cases worldwide • 500,000 deaths SOURCE: “Seasonal Influenza: The Disease.” Centers for Disease Control and Prevention: http://www.cdc.gov/flu/about/disease/index.htm.

3. Impact in the United States • 200,000 hospitalizations • 36,000 deaths SOURCE: “Seasonal Influenza: The Disease.” Centers for Disease Control and Prevention: http://www.cdc.gov/flu/about/disease/index.htm.

4. Prevention • Virus mutates every year • Vaccination • Frequent hand washing SOURCE: "Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP)." MMWR. 54(RR08); July 29, 2005. http://www.cdc.gov/MMWR/PREVIEW/MMWRHTML/rr5408a1.htm.

5. Health Care Workers (HCWs) • Can pass virus to patients and other staff • Influenza infections  low vaccination rates among HCWs SOURCES: "Influenza Vaccination of Health-Care Personnel: Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP)." MMWR. 55(RR02);1-16: February 24, 2006: http://www.cdc.gov/MMWR/PREVIEW/MMWRHTML/rr5502a1.htm. Elder AG, O’Donnell B, McCruden EA, Symington IS and Carman WF. “Incidence and recall of influenza in a cohort of Glasgow healthcare workers during the 1993-4 epidemic: results of serum testing and questionnaire.” BMJ; 313(7067): 1241-2.

6. Policy Recommendations • CDC: Health care facilities “should offer influenza vaccinations to all” health care personnel • The Joint Commission: Require organizations to track employee vaccination rates SOURCES: “Prevention & Control of Influenza - Recommendations of the Advisory Committee on Immunization Practices (ACIP).” MMWR Jul 13, 2007; 56(RR06): 1-54. Lugo, N. “Will carrots or sticks raise influenza immunization rates of health care personnel?” American Journal of Infection Control. February, 2007; Vol. 35, No. 1: 1.

7. Vaccination Rates among HCWs SOURCE: The Centers for Disease Control and Prevention: “Self-reported influenza vaccination coverage trends 1989 - 2008 among adults by age group, risk group, race/ethnicity, health-care worker status, and pregnancy status, United States, National Health Interview Survey (NHIS).” http://www.cdc.gov/flu/professionals/vaccination/pdf/NHIS89_08fluvaxtrendtab.pdf.

8. Mandatory Vaccinations? • H1N1 Influenza spurred some to mandate vaccine • AAP: “Mandatory programs for all [health care personnel] should be implemented nationwide” • Most hospitals and other health care facilities do not mandate vaccination SOURCES: “Policy Statement—Recommendation for Mandatory Influenza Immunization of All Health Care Personnel.” Committee on Infectious Diseases, Pediatrics; published online Sept. 13, 2010: http://pediatrics.aappublications.org/cgi/reprint/peds.2010-2376v1. Stein R. “Mandatory Flu Shots Hit Resistance.” The Washington Post. Sept. 26, 2009.

9. Economics • Traditional economics • Assumes decision-maker is rational • “Making the best choices that further one’s own ends” • Because rational people make few mistakes, policies aren’t necessary to help them • Grossman’s theory of human capital • Individuals invest in themselves • Trade current utility for future utility • Behavioral economics • Relaxes rationality assumptions • Allows for “non-rational” factors SOURCES: Folland S, et al. The Economics of Health and Health Care. Upper Saddle, NJ: Prentice Hall; 2001: 8. Camerer C. “Behavioral Economics: Reunifying Psychology and Economics.” Proc. Natl. Acad. Sci. Sept. 1999; 96: 10575, 10577.

10. Behavioral Economics • What non-rational factors influence decisions? • Health information can lead to improved health behaviors • Limited success • Theory of Reasoned Action • Education is not enough • Intention also determines behavior • Attitude toward behavior • Subjective norms associated with behavior SOURCES: Shumaker SA, Ockene JK and Reikert KA. The Handbook of Health Behavior Change. Hamilton Printing Company, New York; 2009: 21. Richman B. “Behavioral economics and health policy: understanding Medicaid's failure.” Cornell Law Review. Mar 2005; 90(3): 722.

11. Behavioral Economics • Theory of Planned Behavior (TBP) • Attitude toward the behavior • Subjective norms • Perceived behavioral control • Apply TBP to influenza vaccination among HCWs SOURCE: Shumaker SA, Ockene JK and Reikert KA. The Handbook of Health Behavior Change. Hamilton Printing Company, New York; 2009: 21.

12. Dissertation Aims • Analyze and evaluate results of replication of Intranet intervention • Conduct systematic review of literature to determine other ingredients for successful interventions • Recommend policy changes to improve influenza vaccination rates among HCWs

13. Journal Article I: Use of Intranet to Increase Influenza Vaccination Among Health Care Workers

14. Overview • Objective: Evaluate effectiveness of Intranet intervention in increasing influenza vaccination level among HCWs • Design/Methods: New intervention at non-profit, adult hospital which “required” employees to select vaccination status on Intranet. This tactic was accompanied by other, related interventions. • Results: Statistically significant difference in percentage of employees vaccinated: 36.3% in previous year vs. 48.5% in intervention year (P<.001)

15. Cleveland Clinic • 2004-05 flu season: Cleveland Clinic used unique declination form on Intranet SOURCE: Bertin M, Scarpelli M, Proctor AW, et al. “Novel use of the Intranet to document health care personnel participation in a mandatory influenza vaccination reporting program.” American Journal of Infection Control. February, 2007; Vol. 35, No. 1.

16. Cleveland Clinic • Mandatory but not enforced • 90% of HCWs participated • Vaccination rate improved from 38% to 55% • Replication of Intranet intervention at other hospital SOURCE: Bertin M, Scarpelli M, Proctor AW, et al. “Novel use of the Intranet to document health care personnel participation in a mandatory influenza vaccination reporting program.” American Journal of Infection Control. February, 2007; Vol. 35, No. 1.

17. Intervention at St. Luke’s • Similar to Cleveland Clinic • Oct. 2008 – Jan. 2009 • Strategies: • Education and information • Free vaccine • Vaccine easily accessible • Online questionnaire • Pop-up window for declining employees • E-mails to managers

18. Intervention at St. Luke’s • Similar to Cleveland Clinic intervention • Draws on Theory of Planned Behavior • Education not enough • Intention is key determinant of behavior • Attitude • Subjective norms • Perceived behavioral control SOURCE: Ajzen I and Fishbein M. Understanding attitudes and predicting social behavior. Englewood Cliffs, NJ: Prentice-Hall; 1980: 5.

19. Theory of Planned Behavior

20. Data Collection and Analysis • Occupational Health: number of employees vaccinated • Web Center: participation in online questionnaire • Human Resources: average number of employees during intervention • Statistical comparison of employees vaccinated to previous year using Pearson chi-square test (P<0.05)

21. Results • Online Questionnaire: 42.68% participated • 40.02%: Received flu shot this year • 2.67%: Decline flu shot for medical reason • 0%: Choose not to be vaccinated

22. Results • Overall Vaccination Level

23. Results • Intranet intervention associated with increase in vaccination rate among HCWs • Adds strength to Cleveland Clinic study

24. Journal Article II: Use of Interventions to Promote Influenza Vaccination Among American Health Care Workers: A Systematic Review

25. Overview • Objective:Assess current interventions to determine which policies have been the most effective in increasing influenza vaccination rates among HCWs. • Methods:Systematic review of research published between January 1994 and March 2010; studies found in Medline/Pubmed, Ovid and Ebsco databases were included. • Results:Combination of several interventions may prove successful in improving vaccination rates among American HCWs.

26. Systematic Review • Analysis of existing literature • Examine which interventions associated with increase in vaccination rates among HCWs • Identify active ingredients for successful interventions

27. Systematic Review • Peer-reviewed journals Jan. 1994-Mar. 2010 • Effects of interventions for increasing influenza vaccination rates among HCWs • At hospitals, nursing homes, etc. in U.S. • Online databases: • Medline/Pubmed • Ovid • Ebsco

28. Studies Included • 21 studies met initial inclusion criteria • 9 dropped • 12 included for systematic review

29. Interventions • Strong administrative support • Free or no charge • More easily accessible • Education/information campaign • Declination/consent forms • Vaccine “champions” within organization • Incentives

30. Multiple Arm Studies

31. Multiple Arm Studies

32. Multiple Arm Studies

33. Single Arm Studies

34. Results • Multiple Arm Studies: • Education necessary but not sufficient • Increased access associated with higher vaccination rates, but not on its own • Incentives and declination/consent forms may also have impact

35. Results • Single Arm Studies: • Education works best with other interventions • Incentives associated with increases • Easier access has impact as well

36. Results • Combination of interventions may prove successful • Education and easier access seem necessary foundation • Also need: • Declination/consent forms • Incentives

37. Conclusion • Vaccine is best protection against the flu • Short of mandating vaccines, what tools are available to health care organizations? • Intranet-based intervention • Combination of interventions may be most successful • Free vaccine that is easily accessible • Education campaign • Incentives • Online declination/consent form

38. Policy Implications and Recommendations • Changes in institutional policies • The Joint Commission • State governments • Other incentives • U.S.News & World Report • Most Wired Hospitals

39. Further Study • Further testing of Intranet intervention hypothesis • Replication of multiple arm, pre-post intervention study by Zimmerman • Larger systematic review to include interventions from abroad

40. Thank You • Dr. Pauline Rosenau • Dr. L. Kay Bartholomew • Dr. Kay Dunn • Dr. Beatrice Selwyn • Dr. Margaret Price • David Koontz

41. Thank You