Q Manage Health CareVol. 16, No. 1, pp. 51–59c© 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins

The Rate of Influenza Immunization to PeopleAged 65 Years and Older Was Increased From45% to 70% by a Primary Health Care--based

Multiprofessional ApproachBo-Eric Malmvall, MD, PhD; Ingeborg Franzen, BA; Per-Erik Abom, MD;

Maj-Britt Hugosson, RN

For many years, Swedish health authorities haverecommended yearly influenza immunization topersons in medical risk groups and to people aged65 years and older. Despite this recommendation,the vaccination coverage has been lower than 50%in Jonkoping County, as in all other counties ofSweden. To increase the rate of influenzaimmunization in Jonkoping County, we establisheda multiprofessional action group and designed aprimary health care–based program. Importantelements in the project were free of chargevaccination; an education program targetingprimary health nurses; mass media informationthrough advertisements in newspapers, local TV,posters, and handouts; and instituting andimplementing a computerized registry with easyaccess to summary statistics by which each unitcould compare its achievements with others.Personal invitation letters were not used because ofeconomical reasons. The vaccination wasperformed in the county’s health centers and tolesser extent in the hospitals. Most of the healthcenters are owned and run by the county council. Afew health centers are private but have contractwith the county council. Economical incentives tothe providers were not used. During a 4-year period,the immunization rate among all inhabitants of thecounty aged 65 years increased from 45% to 70%.All the 13 municipalities in the county increasedtheir vaccination rate; their recent figures varybetween 61% and 74%. The vaccination rate amongpeople aged 65 years in Jonkoping County is now

the highest in Sweden, but still not as high as insome other European countries. Our influenzaimmunization campaign can act as an example forother healthcare providers.

Key words: influenza immunization, multiprofessionalapproach to immunization, primary health carevaccination, vaccination coverage

S easonal influenza causes considerable mor-bidity and mortality all over the world eachyear. In Sweden, the increased number ofdeaths during weeks with influenza trans-

mission has been calculated to be between 2000 and4000 lives lost.1

The health authorities in most developed coun-tries recommend influenza vaccination to peopleaged 65 years and older. The adherence to this rec-ommendation varies from country to country.2 Al-though Swedish health authorities have strongly rec-ommended that everyone aged 65 or older shall

From the Department of Infectious Diseases, Ryhov Hos-pital, Jonkoping, Sweden (Dr Malmvall and Ms Hugos-son); the Department of Molecular and Clinical Medicine,Division of Infectitions Diseases, University of Linkoping,Linkoping, Sweden (Dr Malmvall); Qulturum, the Institutefor Quality Improvement in Health Care, the County Coun-cil of Jonkoping, Jonkoping, Sweden (Ms Franzen); and theDepartment of Communicable Disease Control, Jonkoping,Sweden (Dr Abom).

Corresponding author: Bo-Eric Malmvall, MD, PhD, De-partment of Infectious Diseases, Ryhov Hospital, S-551 85Jonkoping, Sweden (e-mail: bo-eric.malmvall@lj.se).

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have a yearly injection of the influenza vaccine, thevaccine coverage in the target population was notknown, but estimated to be only been around 30% to40% when this project was planned. There had beenno national campaign to improve the vaccinationrate. The National Board of Health and Welfare(Socialstyrelsen) provides recommendations andproposals on all types of health measures to which the21 different counties have responsibility to adhere to.In 2001, we decided to dramatically improve the rateof influenza vaccination in the inhabitants who wereaged 65 years and older in Jonkoping County. In thisarticle, we describe how we succeeded in improvingthe vaccination rate from 45% to more than 70% in4 years.

THE CAMPAIGN

The campaign started in 2002 and went on for 3years (2002–2004).

Our strategy included the following basic elements:• Free of charge vaccination for all inhabitants

aged 65 years and older.• A multiprofessional campaign team.• Annual education meetings in each of the

county’s 3 districts, focusing on nurses in theprimary health care organization.

• Media campaign using advertisement in TV andnewspapers, designed by professional marketingand public relation experts.

• A Web-based registry that made follow-up statis-tics possible. By using the statistics in the reg-istry, it was possible for the different health cen-ters to follow their own results and compare andcompete with other health centers.

• To give the acting primary health nurses feed-back on their results in order to motivatethem to perform better during the comingyear.

Political decision to give vaccination free of charge

The leader of the campaign who is a specialist ininfectious diseases convinced the political leadersof the county council that yearly influenza immu-nization and 1 injection of vaccine against pneumo-

cocci to people aged 65 years and older and to pa-tients with chronic diseases is a very cost-effectiveintervention. In due time before the 2002 vaccina-tion season, all inhabitants aged 65 and older wereoffered influenza and pneumococcus vaccinationsfree of charge. The health centers were reimbursedwith 30 Swedish crones (SEK; 7.3 SEK = $1) cov-ering the purchase of the influenza vaccine and sy-ringes and 100 SEK for a dose of the pneumococcivaccine. No extra payment was given for staff. Thetop administration of the county council instead con-vinced the health centers and the general practi-tioners (GPs) that the vaccination was an importanttask included in their responsibility to the popula-tion. The decision that influenza vaccination is givenfree of charge was made public through mass mediacampaigns.

Multiprofessional action group

The campaign was initiated by the Head of theDepartment for Infectious Diseases and the county’sHealth Officer for the Prevention of Infectious Dis-eases. These 2 senior physicians were both wellknown in the county and acted as leaders for theproject. A nurse from the Department of InfectiousDiseases with a very long experience of vaccinationand a good knowledge of individual primary healthnurses involved in vaccination became a kind of cen-ter of the team. A professional team leader having ex-perience from previous development projects withinthe health sector became the coach and was responsi-ble for documentation and follow-up of all the stepstaken by the group. The head of the county’s de-partment of information and public relations hav-ing experience in mass media campaigns designedthe information strategy. A computer engineer fromthe county’s Central Department for Computer Ser-vices developed a computerized register that couldbe reached through the county’s internal Web siteby all the health centers. One or two nurses hav-ing experience in vaccination from the health cen-ters in each of the 3 districts of the county becamevery important members of the group by their knowl-edge of local areas and as information ambassadorsout to their vaccinating colleges. We also engaged

Influenza Immunization to People Aged 65 Years and Older in Sweden 53

some nurses working in nursing homes for elderly togain knowledge on the particular circumstances anddifficulties in vaccinating very old and institutional-ized people.

Needed knowledge

The action group started half a year before the 2002vaccination period by doing a research on presentand also missing knowledge within the group. Wefound that we had to know more about the opin-ion and the attitudes toward influenza immunizationamong the old population group in the county. Weinterviewed 15 old people and obtained some valu-able information concerning believes and attitudestoward influenza immunization. This new knowl-edge was very valuable in the designing of the massmedia campaign. We also sent a questionnaire to anumber of nurses who we knew were involved invaccination at different health centers. From their re-sponses, we improved our knowledge about routinesand logistics in the health centers.

Education program

The GPs employed by the county were informedabout the campaign in 2 regular educational meetingsduring the spring of 2002, reaching more than 90%of all GPs in the county.

The action group planned and performed educa-tional meetings including a particular program de-signed with focus on senior nurses in the primarycare. One meeting was held in each of the 3 districtsof the county. The meetings started with lunch, andduring 3 hours, about 300 nurses from all the healthcenters in the county were encouraged to performinfluenza immunization. The educational packageincluded theoretical knowledge on influenza, the ef-ficacy of the vaccination, the safe way to give injec-tions intramuscularly, health economic effects, andalso practical advice on how to arrange the vaccina-tion with proper logistics.

The physicians in the action group as well as someof the nurses acted as lecturers, giving both the the-oretical and practical advice on how to organize thevaccination hours in the health centers.

Mass media campaign

The professional marketing people arranged a me-dia campaign, as given in Table 1. In these acts, anold-fashioned nurse called Gladys advocated withboth humor and anger the need for influenza im-munization for people aged 65 and older. She wasused both in the advertisements in newspapers andlocal TV shots and in posters and brochures (Fig 1).Gladys was seen all over the county. The media cam-paign has been repeated every year since 2002 inconnection with the beginning of the vaccinationperiod.

Web-based registry

The action group prepared a long list of requestedcontent for a computer-based registry. It was Web-based, easy to reach through the county’s internalWeb site, and easy to handle. It included a func-tion for statistical analysis. During some months inthe summer of 2001, the computer department ofthe county council prepared a Web-based computerprogram in which all the health centers and as wellas vaccinating hospital department could register allvaccinations given. The program also included a sta-tistical part by which each unit could compare itsresults with that of others. The registry was used tocheck whether old people might have been vacci-nated earlier in another unit during the same season.The registry was easy to work with and rapidly ac-cepted by the users. After a short pilot period, someadjustments were made and after that the registry wasready to be implemented. About 150 secretaries weretrained to master the registry in their different units.The same registry has been in use since 2002, withonly minor modifications.

The registry made it easy to give feedback to differ-ent units, and created a prerequisite for a competitionbetween the health centers.

Questionnaire

During the 2002 vaccination season, approxi-mately 500 old people were asked some questionsthrough a written questionnaire about how they wereinformed about influenza vaccination, where they

54 QUALITY MANAGEMENT IN HEALTH CARE/VOLUME 16, ISSUE 1, JANUARY–MARCH 2007

Table 1

THE OUTLINE OF THE MEDIA CAMPAIGN ON INFLUENZA IMMUNIZATION IN JONKOPING COUNTY2003–2004

Media When Cost

Household magazine “Landstings Nytt”: First page:Photograph of “Gladys” Article about “Gladys”and the reasons why one should get vaccinated

Delivery: October 6–7

Internal magazine “Pulsen”: Interview withElisabeth Carlstrom, “Gladys Hurtig” (Pulsen no.5 2002)

Delivery: September 11–12

TV advertisement in local TV channel: “Gladys”requests the people to get vaccinated

Weeks 41 and 42 (October 7–20) 6 × 2 spots = 12 (20 SKReach) (total 39,032 SKR)

Advertisements in daily press: “Vaccinera dig!”(Get vaccinated!) “Jonkopings-Posten,”“Varnamo Nyheter,” “Smalands Tidningen” witheditions

Week 41 (October 7–13), withrepeat on week 43 (October21–27)

Approximately 22,000 SKR(8.624 + 8.202 + 5.148 =21.974∗)

Advertisement template to health centersclinics: Atemplate for opening hours and otherinformation

Delivery: September 25–27

Poster in waiting rooms, pharmacies: “Keep theinfluenza away!”

Delivery: September 25–27 1000, size A3 (total 7500SKR)

Leaflets 1 and 2: 1. “0 krona to avoid theinfluenza. That was cheap!”

Delivery: September 25-27 1000, size A4 (total 3750SKR)

2. “One dose to avoid the influenza. That waseasy!”

Delivery: October 14–18

Folder: “Five questions and answers aboutinfluenza vaccination”

Delivery: September 29 Approximately 4000 SKR,300–600 SKR to eachhealth center

Press activities in Jonkoping, Varnamo, and Eksjo Weeks 41–42

∗7.3 SKR = $1.

had been vaccinated, and how long the waiting timewas. We found that the newspapers, TV, and thecounty’s house magazine were 3 powerful informa-tion channels in addition to person-to-person infor-mation and discussions with relatives and friends.

Project connected with pursuing perfection

Within the pursuing perfection project, the countyhad started cooperation with Institute of Health Im-provement in Boston, Mass, during 2001. It was bothtimely and useful to adhere to a strategy outlined inthe pursuing perfection work, with goals in differentperspectives (Box 1).

Under the heading effectiveness, we set up a num-ber of subgoals. For the first year in 2002, the totalvaccine coverage should be 60% and in no munici-

pality less than 50%. The top municipalities shouldreach 75% in the same year. The rate of vaccinationin the county should reach 68% during the secondyear, 2003.

Measurements of results

The rate of people older than 65 years vaccinatedfor influenza in 2002 and the years thereafter is calcu-lated from the number of vaccinations registered andrelated to the population in the county and in eachmunicipality. In 2001 and before, the vaccination rateis calculated from the number of doses delivered tothe county. We have assumed according to the expe-rience from 2002 and 2003 that 10% of the deliveredvaccine doses are used by people aged younger than65 years.

Influenza Immunization to People Aged 65 Years and Older in Sweden 55

Figure 1. Picture of Gladys. Produced by the Department for Information and Public Relations, County Council, Jonkoping,Sweden.

Repeated campaigns for 2003 and 2004

The design of the project in 2002 was repeated asprojects during 2003 and 2004. Experiences drawn

Box 1

PatientSafety Effectiveness Timeliness Efficiency centeredness Equity

No allergicreactions inpatients withknown allergyto eggs

Vaccine cover<75% ofinhabitants olderthan 65 years in2004

No waiting timefor the patient

Vaccinationperformed inrelation toordinary care inall possiblesituations

Vaccinationperformed in atime appropriatefor the patient

100% will havethe same offerregardless ofliving place andalso knowledgein Swedish

during the first year was used in the campaign in thesecond and third years. The education of the nursesstressed much more on the role of the local organiza-tion and the logistics within the health centers. We

56 QUALITY MANAGEMENT IN HEALTH CARE/VOLUME 16, ISSUE 1, JANUARY–MARCH 2007

Figure 2. Rate of influenza vaccination for inhabitants aged 65 years and older in Jonkoping County, Sweden.

had unfortunate reports in 2002 that the old peoplereturned home because of long waiting time at thevaccination hours during the first week of the vacci-nation period. We learnt that most old people wantedto have the immunization done during the first daysof the campaign. The logistics inside the health cen-ters were improved and the numbers of open vacci-nations hours was increased.

The mass media campaign was repeated everyyear. “Gladys” became well known to the popu-lation through television shots and advertisementin the daily newspapers, and has become a localcelebrity.

Competition between health centers

The primary health nurses responsible for the vac-cination received feedback at a meeting after the vac-cination season, where the vaccination coverage inall municipalities were discussed and the figures ofeach municipality were compared to others and to thetotal of the county. In this way, a competition arosebetween the vaccinating health centers. This compe-tition continued, as every health centers had real timeaccess to the statistics in the registry. There were noprices, just the honor of having achieved high vacci-nation coverage.

Influenza immunization after the project period

From 2005 onwards, influenza vaccination is nota special project, but is performed as an ordinaryresponsibility of the county’s Health Officer for thePrevention of Infectious Diseases. However, the samestrategy is still being used. The immunization of peo-ple 65 years and older is still free of charge, a massmedia campaign is being used, and new nurses at thehealth centers are educated.

RESULTS

Safety

All customers were asked, “Are you allergic toeggs?” prior to the vaccination on an information pa-per and orally by the nurse giving the injection. Thevaccinated persons were asked to report allergic re-actions back to their health centers. We had just onereport of a mild allergic reaction in a man who didnot report his allergy, but when he came home, hewas reminded by his wife about his allergy.

Effectiveness

As can be seen in Figure 2, the rate of vaccinatedpeople 65 years and older has increased from 45% in2001 to 70 % in 2005.

Influenza Immunization to People Aged 65 Years and Older in Sweden 57

Figure 3. Rate of influenza vaccination in different age groups in Jonkoping County in 2004.

The vaccine coverage increased with higher age.Seventy-five percent of the inhabitants older than90 years were vaccinated compared with 57% in theage group younger than 70 years (Fig 3).

Timeliness

All health centers arranged several open hours forvaccination during 2 to 3 weeks. In an enquiry givento 500 vaccinated people, it was obvious that thewaiting time in many health centers were too longduring the first year. It improved in 2003 and 2004.

Efficiency and patient centeredness

In 2004, the rate of patients vaccinated in rela-tion to admissions or outpatient visits at hospital was2.6% . It was not possible to trace the number of vac-cinations on ordinary visits to a health center in theregistry.

Inequity

The vaccination rate has increased in all years dur-ing the project in all municipalities, with just 2 ex-

ceptions. In 2004, the rate varied between 60% and74% (Fig 4).

There are very few immigrants in our county inthe age group of 65 or older, so we decided not toput money and efforts to reach these people in theirlanguage. Most of the old immigrants have relativeswith good knowledge of Swedish.

DISCUSSION

Since more than 20 years, the national medicalauthority (the National Board of Health and Wel-fare) in Sweden has recommended influenza immu-nization to medical risk groups and to people aged65 years. This recommendation was strengthened in1997, but still the vaccination rate continues to belower in Sweden than in many other comparablecountries.1,2 Strong recommendations alone were notenough. Obviously, the Swedish physicians did notfollow the instructions from authorities.3 The stud-ies in Stockholm4 and in Minnesota5 show that in-fluenza vaccination as highly cost-effective measure

58 QUALITY MANAGEMENT IN HEALTH CARE/VOLUME 16, ISSUE 1, JANUARY–MARCH 2007

Figure 4. Rate of influenza vaccination for inhabitants aged 65 and older in the municipalities of Jonkoping County, Sweden.

seemed not to have increased the efforts to performlarge-scale influenza immunization.

We believe that a campaign must be launched in or-der to change the behavior of the primary health sys-tem in this respect. We did not blame the GPs for theirinsufficiency, but stimulated primary health care asa system to perform better immunization coverage.

Our campaign included many important elements.We convinced the public through a mass media cam-paign that influenza immunization is important andvaluable for them. The campaign was led by a publicrelation professional and was based on knowledge ofpeople’s attitudes toward influenza immunization.

The elected political leaders and the head office ofthe county were convinced that influenza immuniza-tion is a cost-effective measure and is worth given freeof charge. Without the support from the top leaders,it would have not been possible to raise necessary

funds for the different elements in the project.The legitimacy and the status of the action group

was probably very important in the relationshipswith the public, county leaders, and staff in all thevaccinating units.

The registry and the transparency in the statisticscreated a competition between the health centers,which tended to increase their efforts to reach highervaccination rates.

Our project can be described as both a top-downand a bottom-up strategy. Top-down strategy wasused to point out what should be done and to setthe goals. The latter strategy was used to implementthe program.

We gave a full responsibility to primary healthnurses to organize and perform the vaccination atthe health centers. The idea was that the GPs arevery busy and have not been able to show up good

Influenza Immunization to People Aged 65 Years and Older in Sweden 59

rates of immunization before. The strategy of provid-ing education to senior nurses and giving them theresponsibility resulted in a very enthusiastic partic-ipation in the campaign in all health centers. Thefeedback through the registry probably fuelled thisenthusiasm.

We think that cooperation among many differentexperts is necessary and can result in an improvedcoverage of influenza immunization rates.

The goal was set as high as 75% coverage on the ba-sis of reports of vaccination rates in the Netherlandsand France. Although we did not reach the goal, wefeel that targets are important in our struggle. The re-sult with an improved vaccination rate from approx-imately 45% to 70% in just 4 years is not bad, andour county has achieved the top position in Sweden.Our system of registration of all vaccinations givenand reimbursement of the costs to the vaccinatingunits according to the registry gave us an exact andsafe figure on the coverage. Other reports on vac-cination coverage are usually based on populationsurveys.6

When the project was handed over as the routineresponsibility of county’s Department of Communi-cable Disease Control, the rate continued to increaseto 70%. We do think that we have been able to in-troduce a new habit among the older people so thatwhen October comes and they see in the newspapersand on TV, they know that it is time to go and gettheir influenza vaccination.

The local medical authorities in Stockholm haveperformed a similar campaign to ours. In addition toa mass media campaign, coupons were sent by post toall people aged 65 or older, and with this coupon, ev-eryone could get their influenza immunization free ofcharge at private clinics or from physicians employedby the county. Influenza vaccination was reimbursedwith 100 SEK for each coupon being sent back to theauthorities.4 We were also discussing this strategy inour county, but found it to be expensive with respectto the postage costs. As most of our GPs are employedor having a contract with the county, the top healthcare management and we assumed that it is a ba-sic responsibility of all health centers to perform theimmunization recommended by national authorities.

The reimbursement to our health centers was exactlyequal to the cost of the vaccine itself.

The results of our project have spread in thecountry through an article in a national medicaljournal and by national conferences. Many coun-ties have started projects with similar strategies. Thevaccination rate in Jonkoping County is howeverstill the highest among all 21 Swedish counties.7

But in comparison with other countries in WesternEurope, we still have a way to go until we reachthe rate of influenza immunization of 81% to peopleaged 65 years and older, which is the national figurefor the Netherlands.6 One of the national health ob-jectives for 2010 in the United States is to achieveinfluenza vaccination coverage of 90% for personsaged 65 years and older. The national influenza vac-cine coverage in 2004 in the United States amongpersons aged 65 years and older was estimated tobe 65%.8

REFERENCES

1. Uhnoo I, Linde A, Pauksens K, Lindberg A, Eriksson M, NorrbyR, for the Swedish consensus group. Treatment and preventionof influenza: Swedish recommendations. Scand J Infect Dis.2003;35:3–11.

2. Kroneman M, Paget WJ, van Essen GA. Influenza vaccina-tion in Europe: an inventory of strategies to reach target pop-ulations and optimise vaccination uptake. Eurosurveillance.2003;8:130–138.

3. Lindberg A. Stor geografisk variation av vaccination bland aldre.Lakartidningen. 2004;24:20–80.

4. Christenson B, Lundbergh P, Hedlund J, Ortqvist A. Effects of alarge-scale intervention with influenza and 23-valent pneumo-coccal vaccines in adults aged 65 years or older: a prospectivestudy. Lancet. 2001;357:1008–1011.

5. Nichol KL, Margolis KL, Wuorenma RN, von Sternberg T. Theefficacy and cost effectiveness of vaccination against influenzaamong elderly persons living in the community. N Engl J Med.1994;331:778–784.

6. Kroneman MW, van Essen GA, Tacken MAJB, Paget WJ, VerheijR. Does a population survey provide reliable influenza vac-cines uptake rates among high-risk groups? A case study of theNetherlands. Vaccine. 2004;22:2163–2170.

7. Malmvall BE, Abom PE. Influensa vaccination av alla over65 ar—utopi eller mojlighet. Lakartidningen. 2004;101(51–52):4196–4201.

8. Smith, NM, Bresee JS, Shay DK, et al. Prevention and con-trol of influenza. Recommendations of the Advisory Commit-tee on Immunization Practices (ACIP). MMWR Recomm Rep.2006;55(RR10);1–42.