Seasonal influenza vaccination of healthcare workers: systematic review of qualitative evidence

Lorenc et al. BMC Health Services Research (2017) 17:732 DOI 10.1186/s12913-017-2703-4 RESEARCH ARTICLE Open Access Seasonal influenza vaccination of healthcare workers: systematic review of qualitative evidence Theo Lorenc1* , David Marshall1, Kath Wright1, Katy Sutcliffe2 and Amanda Sowden1 Abstract Background: Most countries recommend that healthcare workers (HCWs) are vaccinated seasonally against influenza in order to protect themselves and patients. However, in many cases coverage remains low. A range of strategies have been implemented to increase uptake. Qualitative evidence can help in understanding the context of interventions, including why interventions may fail to achieve the desired effect. This study aimed to synthesise evidence on HCWs’ perceptions and experiences of vaccination for seasonal influenza. Methods: Systematic review of qualitative evidence. We searched MEDLINE, EMBASE and CINAHL and included English-language studies which reported substantive qualitative data on the vaccination of HCWs for seasonal influenza. Findings were synthesised thematically. Results: Twenty-five studies were included in the review. HCWs may be motivated to accept vaccination to protect themselves and their patients against infection. However, a range of beliefs may act as barriers to vaccine uptake, including concerns about side-effects, scepticism about vaccine effectiveness, and the belief that influenza is not a serious illness. HCWs value their autonomy and professional responsibility in making decisions about vaccination. The implementation of interventions to promote vaccination uptake may face barriers both from HCWs’ personal beliefs and from the relationships between management and employees within the targeted organisations. Conclusions: HCWs’ vaccination behaviour needs to be understood in the context of HCWs’ relationships with each other, with management and with patients. Interventions to promote vaccination should take into account both the individual beliefs of targeted HCWs and the organisational context within which they are implemented. Keywords: Healthcare workers, Influenza, Qualitative research, Systematic review, Vaccination Background Most countries recommend that healthcare workers (HCWs), at least those involved in direct patient care, are vaccinated against influenza each winter [1]. Seasonal influenza vaccination can help to protect not only HCWs but also patients against infection. A recent systematic review found that vaccination of HCWs significantly reduced influenza-like illness and all-cause mortality among patients, [2] although results for other outcomes such as number of working days saved are more equivocal [3]. * Correspondence: 1 Centre for Reviews and Dissemination, University of York, York YO10 5DD, UK Full list of author information is available at the end of the article However, many HCWs decline vaccination. Vaccine coverage among HCWs in the USA has surpassed 75%, [4] but in many European countries it remains below 30% [5]. A range of strategies have been implemented to increase vaccination among HCWs. A recent systematic review indicates that mandatory vaccination policies, awareness-raising and interventions to increase the accessibility of vaccination are likely to be effective, but that incentives and education are ineffective [6]. Many quantitative studies have examined HCWs’ attitudes to vaccination and the determinants of vaccination uptake [7]. Qualitative evidence may complement these quantitative data by highlighting potential barriers and facilitators of vaccination uptake, which can then be targeted in future interventions and strategies. © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Lorenc et al. BMC Health Services Research (2017) 17:732 The aim of this systematic review was to synthesise evidence on HCWs’ perceptions and experiences of vaccination for seasonal influenza. It was commissioned by the Department of Health in England to inform the development of policy on vaccination of HCWs. We used a systematic approach, with pre-defined inclusion criteria and a reproducible methodology. However, due to the need to provide a timely synthesis of the evidence for policy decision-making, we streamlined our approach to data analysis, which was conducted by a single reviewer and focused on the identification of key themes, rather than on producing a critical synthesis or developing third-order constructs. Further interpretations of the data are explored in the discussion below. Methods We followed CRD Guidance on Undertaking Systematic Reviews [8]. Searching We searched MEDLINE, EMBASE and CINAHL in May–June 2016. The search strategy took the form: (terms for HCWs) AND (terms for vaccination) AND (terms for influenza) AND (terms for views and qualitative research). The full MEDLINE search strategy is presented in webonly Additional file 1. No date or language restrictions were applied to the search. We searched Google using simplified forms of the search strategy and scanned the first 100 results, and manually searched websites of key organisations including NHS Employers, Centers for Disease Control and Prevention and the World Health Organization. We screened a recently published review evaluating the effectiveness of interventions to increase influenza vaccine uptake for any linked qualitative data [6]. We scanned the lists of included studies of potentially relevant systematic reviews identified by the search, and the reference lists of all included studies. We carried out forward citation chasing on all included studies using Google Scholar. Screening A 10% sample of abstracts was screened by two reviewers independently and differences resolved by discussion. Agreement on inclusion for this sample was 99.4% (κ = 0.66). The remaining 90% were screened by a single reviewer. The following inclusion criteria were applied: 1) Qualitative research 2) Study reports data on seasonal influenza vaccination 3) Study includes HCWs 4) Study published in English 5) (full-text only) Study reports substantive qualitative data (i.e., more than one or two relevant data points, or a very brief summary of findings) Page 2 of 8 All full-text studies were screened by two reviewers independently and differences resolved by discussion. Quality assessment, data extraction and synthesis We used Hawker et al.’s tool to assess study quality [9]. Quality assessment wa (...truncated)