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influenza vaccine hesitancy
by Ryan Hamilton and Adam Baker
School of Pharmacy, De Montfort University, Leicester, UK
Published on 4 November 2021

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The challenges of influenza vaccine hesitancy in hospital pharmacy staff

Vaccine hesitancy is a complex issue that affects hospital pharmacy staff receiving the influenza vaccine. This article discusses the drivers for uptake and hesitancy, and proposes interventions to address this

Every year, 4,000,000–50,000,000 people across Europe (EU/EEA) develop symptomatic influenza, of which 15,000–70,000 will die.1 Influenza vaccines are safe and effective, preventing millions of infections every year and protecting thousands of individuals from developing serious disease or dying. Vaccination is also deployed to protect groups at risk of severe disease such as older people, pregnant women, and people with conditions such as chronic obstructive pulmonary disease and diabetes. Notably, being vaccinated offers extended protection to those in close-contact due to reduced transmission. Pharmacists, and the wider pharmacy team, undertake a range of patient-facing and non-patient-facing roles that will expose them to influenza. These pharmacy staff can then disseminate the virus to vulnerable patients, other health professionals, and their family and friends.2 Therefore, it is imperative for pharmacy staff to be vaccinated every winter.

Pharmacy teams can also play an important role in providing vaccination. During the 2020–21 influenza vaccination programme in England (UK), community pharmacists administered around 2.6 million influenza vaccines, an increase from 1.7 million delivered the previous year,3 possibly driven by society’s reliance on community pharmacies during the COVID-19 pandemic. Pharmacy’s involvement has been focused in primary care and there are few data on the role of secondary care pharmacy professionals, possibly because it is not an expected role for secondary care.

A significant proportion of pharmacy staff do not receive their annual vaccine against influenza. National and European (through ECDC) monitoring programmes and published research often fail to appreciate the diverse workforce within hospital pharmacy services and often groups pharmacists and pharmacy colleagues in with other allied health professionals or clinical support services. This makes it difficult to truly understand influenza vaccine uptake among hospital pharmacists, pharmacy technicians, and other support colleagues.

Vaccine hesitancy

The SAGE working group on vaccine hesitancy defines it as a “delay in acceptance or refusal of vaccination despite the availability of vaccination services. Vaccine hesitancy is complex and context specific, varying across time, place, and vaccines. It is influenced by factors such as complacency, convenience and confidence”.4

Global research suggests influenza vaccination uptake among hospital pharmacists varies between 39% and 95%, depending on the country and setting.5–7 Hamilton et al8 is the only group to report the attitudes and beliefs surrounding influenza and the vaccine, correlating this with vaccine uptake and intention, across the full spectrum of pharmacy professionals working in UK hospitals. The study, involving 170 participants, found that 50.6% had been vaccinated, 17.1% had not been vaccinated but intended to be, and 32.4% had not been vaccinated and had no intention to be vaccinated. Differences were observed between staff groups (Figure 1) and participant age. It is not clear what is driving this difference in vaccination attitudes and uptake between staff groups, but education and training, particularly preregistration training, could be an underlying driver. Younger age correlated with decreased vaccine uptake, which is also true of the general population.

The literature also suggests that access to influenza vaccines is a common barrier to vaccine uptake among busy hospital workers, even those holding positive beliefs and attitudes regarding vaccination.9,10 However, UK research suggests the influenza vaccine is easily accessible to hospital pharmacy staff and this is not a barrier.8 This could be due to hospital occupational health services coordinating peer-vaccination programmes, whereby health professionals are trained to administer influenza vaccines to their colleagues in their area of employment, such as dispensaries, wards, offices, and even dining and break areas, etc. Regardless of this easy and direct access to influenza vaccination in hospitals, many pharmacy staff are making a conscious decision to not be vaccinated.

Attitudes and beliefs that contribute to vaccine hesitancy are vast and there is rarely only a single negative belief that drives hesitancy (Figure 2). As indicated in the definition by SAGE, vaccine hesitancy is complex and the literature suggests these beliefs and attitudes interlink and influence each other.4,8 Research into this phenomenon has highlighted a number of key beliefs and attitudes that correlate to vaccine hesitancy, shown below.

Believe they are not at risk of influenza

This can be further separated into two sub-groups. 

  • Individuals do not believe they are at risk of contracting the virus: This can be driven by misunderstanding influenza transmission, but equally, it can be a judgement based on their personal and work environments. For example, pharmacy staff working solely in a dispensary or office might perceive their risk to be lower than those working in patient-facing clinical roles. Research has shown that pharmacy staff working in a cardio-respiratory hospital were more likely to be vaccinated than those working at other hospitals.8
  • Individuals do not believe influenza is a severe disease or that they are not at risk of severe disease: This often correlates with the belief that the immune system protects the individual from influenza and severe disease. This is a well-documented belief that drives vaccine hesitancy among pharmacists, other health professionals, and the general public.4,11 Younger individuals holding this belief might claim their age and self-identified good health makes them less likely to have severe disease.
Do not believe the vaccine is effective

Misconceptions regarding influenza vaccine efficacy are common among the general public and health professionals.12,13 Individuals holding this belief may quote statistics from the media, particularly from years where the match between circulating and vaccine strains was poor, to suggest vaccination is not worthwhile. However, these individuals are often not aware of the extended benefits if they do contract influenza, such as preventing or reducing severe disease, hospitalisation, and death but also preventing transmission to others.14

Concerned about adverse effects of the vaccine

Concerns about adverse effects are broad and range from needle-phobia to injection-site pain in the days following vaccination. Some individuals are hesitant about future vaccination due to previous common adverse reactions to vaccines such as fainting, fever, malaise, aches and pains.7,15 Interestingly, a number of health professionals still believe the inactive intramuscular vaccine can cause influenza disease, which has been linked to driving vaccine hesitancy.7

Overcoming barriers

Due to the complexities surrounding influenza vaccine hesitancy, no single intervention or message will overcome these barriers, so multiple barriers need to be addressed simultaneously. These barriers should also be considered in other vaccine programmes, particularly COVID-19, early in the service design process and during each annual service review.

Health professionals who receive the influenza vaccine and hold positive vaccine attitudes are more likely to believe that vaccination should be mandatory for health professionals, but data suggests this is not always effective in increasing vaccine uptake. The COVID-19 pandemic has seen vaccination mandated for health professionals in a number of countries but is, unsurprisingly, controversial with many arguing it removes personal rights and freedoms and could be open to legal challenge.16 Given the objections to mandated vaccination, more persuasive interventions are required initially. Individuals who believe it is their professional responsibility and regulatory expectation to be vaccinated are more likely to be vaccinated,8 therefore pharmacy regulators across the EU should look to add this to their professional standards for registrants.

Improving access to vaccination is imperative. If staff perceive it as too difficult to access, relative to their job commitments, they will be less likely to make the effort to seek vaccination.10,17 This barrier can be removed by providing vaccinations free of charge directly at the place of work for pharmacy staff such as clinics, offices, staff rooms, and dispensaries. Many UK hospitals run peer-vaccinator programmes each winter, whereby health professionals act as vaccinators for other members of staff. Anecdotal evidence suggests hospital pharmacists do not act as peer-vaccinators to the same extent as their nursing and midwifery colleagues. This is a missed opportunity to increase availability of vaccination within pharmacy departments but is also a missed opportunity for pharmacists to act as vaccine advocates to their peers and other members of the pharmacy team (see Figure 3). There is also a possibility that peer-vaccinators can help recipients overcome or manage their needle-phobia. In many countries there are mechanisms by which pharmacy technicians can administer influenza vaccines, which should be explored to improve access further, create strong professional advocates for vaccination amongst technical staff, and expand the role of this core member of the pharmacy team.

Health professionals acting as advocates and educators can improve vaccine attitudes and uptake amongst their colleagues.17 Knowledge of a manager’s vaccine status has also been shown to increase uptake among employees.18 Therefore, being vaccinated and promoting vaccine benefits to their colleagues can go some way to increasing overall vaccine uptake, even if they are not a peer-vaccinator.

As well as being vaccine advocates, pharmacy professionals can provide annual education and myth-busting for their colleagues. Those who are not vaccinated are less likely to appreciate the extended protection for patients, colleagues, and family with research suggesting knowledge of these extended benefits significantly increases vaccination rates.12,19 Good understanding of influenza and vaccination has been shown to correlate with increased vaccine uptake.17,20 However, ad hoc post-registration education is not always successful in increasing vaccine uptake,21,22 and it is unclear whether education strategies should be universal11 or profession-focused.23 Therefore, it is imperative to include transmissible and preventable diseases, vaccine science, and behaviour science within pre-registration curricula for pharmacists, pharmacy technicians, and other support staff. Moreover, pre-registration training programmes should also include vaccine administration training. 

Finally, senior managers should consider incentivising vaccination for their staff, to help increase uptake by providing an immediate benefit or gain. Examples of successful incentives that are successfully used in hospital staff vaccination programmes are vouchers for a free meal, being entered into a prize-draw, or even providing staff with additional leave.17,23 

References
  1. European Centre for Disease Prevention and Control. Factsheet about seasonal influenza. 2021. www.ecdc.europa.eu/en/seasonal-influenza/facts/factsheet.
  2. Jenkin DC et al. A rapid evidence appraisal of influenza vaccination in health workers: An important policy in an area of imperfect evidence. Vaccine X. 2019;Jul 11;2:100036
  3. Pharmaceutical Services Negotiating Committee. Over 2.6 million flu vaccinations administered by community pharmacists during 2020/21. https://psnc.org.uk/our-news/over-2-6-million-flu-vaccinations-administered-by-community-pharmacists-during-2020-21/.
  4. MacDonald NE et al. Vaccine hesitancy: Definition, scope and determinants. Vaccine 2015;33:4161–4.
  5. Ruiz AD et al. Influenza vaccination rates among pharmacists. J Am Pharm Assoc 2010;0:517–22.
  6. Black CL et al. Influenza Vaccination Coverage Among Health Care Personnel — United States, 2014–15 Influenza Season.MMWR  Morb Mortal Wkly Rep 2015;64:993–9.
  7. Alshammari TM at al. Health care professionals’ awareness of, knowledge about and attitude to influenza vaccination. Vaccine 2014;32:5957–61.
  8. Hamilton RA, Krockow EM, Vekria P. Attitudes towards influenza and uptake of the flu vaccine: A survey of pharmacy staff working in English hospitals. Vaccine 2021;39:2636–42.
  9. Hofmann F et al. Infection Influenza Vaccination of Healthcare Workers: a Literature Review of Attitudes and Beliefs. Infection 2006;34:142–7.
  10. Shrikrishna D et al. Influenza vaccination for NHS staff: attitudes and uptake. BMJ Open Respir Res 2015;2:e000079.
  11. Knowler P, Barrett M, Watson DAR. Attitudes of healthcare workers to influenza vaccination. Infect Dis Health 2018;23:156–62.
  12. Boey L et al. Attitudes, believes, determinants and organisational barriers behind the low seasonal influenza vaccination uptake in healthcare workers – A cross-sectional survey. Vaccine 2018;36:3351–8.
  13. Ajenjo MC et al. Influenza vaccination among healthcare workers: ten-year experience of a large healthcare organization. Infect Control Hosp Epidemiol 2010;31:233–40.
  14. Sundaram N et al. “I wouldn’t really believe statistics” – Challenges with influenza vaccine acceptance among healthcare workers in Singapore. Vaccine 2018;36:1996–2004.
  15. Sánchez-Payá J et al. Influenza vaccination among healthcare personnel after pandemic influenza H1N1. Vaccine 2012;30:911–15.
  16. Dubov A, Phung C. Nudges or mandates? The ethics of mandatory flu vaccination. Vaccine 2015;33:2530–5.
  17. Stead M et al. Improving uptake of seasonal influenza vaccination by healthcare workers: Implementation differences between higher and lower uptake NHS trusts in England. Infect Dis Health 2019;24:3–12.
  18. Vallée-Tourangeau G et al. Motors of influenza vaccination uptake and vaccination advocacy in healthcare workers: Development and validation of two short scales. Vaccine 2018;36:6540–5.
  19. Toledo D et al. Knowledge of and attitudes to influenza vaccination among community pharmacists in Catalonia (Spain). 2013–2014 season: A cross sectional study. Int J Environ Res Public Health 2017;14:756.
  20. Kadi Z et al. Barriers of influenza vaccination in health care personnel in France. Am J Infect Control 2016;44:361–2.
  21. To KW et al. Increasing the coverage of influenza vaccination in healthcare workers: review of challenges and solutions. J Hosp Infect 2016;94:133–42.
  22. Doratotaj S, Macknin ML, Worley S. A novel approach to improve influenza vaccination rates among health care professionals: A prospective randomized controlled trial. Am J Infect Control 2008;36:301–3.
  23. Hollmeyer H et al. Review: interventions to increase influenza vaccination among healthcare workers in hospitals. Influenza. Other Respir Viruses 2013;7:604–21.


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