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IMMUNIZATION BARRIERS AND
ENABLERS AMONG HEALTH CARE
PROFESSIONALS: ANALYSIS OF
FINDINGS
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1. Introduction
HProImmune is a 3-year project funded by the DG SANCO Public Health Program 2008 – 2013 aiming
to promote immunization among Health Care Workers (HCWs) in Europe.The project will add to the
knowledge on barriers concerning HCW immunizations and develop educational material for health
professionals in both the private and the public sector, as well as propose recommendations for policy-
makers.
The general objective of this project is to promote vaccination coverage of HCWs in different health
care settings by developing a tailored communication toolkit.The specific objectives of the project
Increase awareness about the most important vaccine preventable diseases, which pose a
particular risk to EU HCWs
Increase awareness about immunizations among HCWs through a database comprising
vaccination specific information from across the EU
Provide new knowledge about vaccination behaviors and barriers among HCWs
Identify best practices for the immunization of health professionals
Provide new knowledge on how to communicate and promote immunizations among HCWs by
piloting a purpose and tailor-made Immunization Toolkit
Increase awareness and promote HCW immunizations through a widely disseminated and pilot
tested HCW Immunization Promotion ToolKit comprising recommendations, communication
guidelines, tools and fact sheets.
Prior to designing the HproImmune toolkit it was necessary to conduct an in depth exploration of
immunization barriers and enablers towards vaccination among Health Care Professionals. This was
necessary in order to enhance understanding of risk perception, behaviors towards vaccination and
barriers inhibiting HCWs from immunization.
This report presents the main findings and implications for the HproImmune toolkit as emerged from the
research conducted through the HProImmune survey and the focus groups.
2. Methodology
Qualitative and quantitative methodology was followed in order to acquire a comprehensive
understanding of the issues in all of the countries comprising the HProImmune consortium but also
across the EU. In particular an online survey was developed so as to cover as many EU Member States
as possible as well as focus groups conducted by all HProImmune partners.
2.1 Surveyquestionnaire The HproImmune questionnaire was developed by the partner consortium and the project Advisory
Board. It comprises14 questions that explore vaccination barriers and enablers for specific vaccine
preventable diseases among various categories of HCP. In particular Q1-Q7 explored
demographicinformation including gender, age, and country of work, education, specialty, work setting
and years of experience. Q8-Q14 explored behavior towards vaccines asking respondents questions
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about risk perception of Vaccine Preventable Diseases (VPDs), vaccination coverage in the past 10yr,
reasons for being immunized or not being immunized and attitudes towards obligatory vaccination.
The survey was uploaded on the HProImmune website and is available in 10 languages namely English,
Greek, Italian, Spanish, Polish, Romanian, German, Swedish, Lithuanian and French.
Responses were analyzed through the statistical package SPSS 21. The statistical tests applied for the
analysis of data included apart from descriptive analysis pearson chi square and logistic regression
analysis.
2.2 Focus Groups Focus groups were conducted in all the consortium countries namely Greece, Cyprus, Italy, Poland,
Lithuania, Germany, and Romania. The conveniencesample comprised 282 HCWs and participants
were recruited from hospitals and other settings.
The focus group approach was selected for data collection as it involves and uses group interaction to
generate data. Before beginning the focus group interviews a questionnaire was administered to collect
information about socio-demographics, and work experience of the participants. For most the focus
group offered a unique opportunity to express their feelings, to provide distinctive types of data and to
clarify their attitudes to vaccination in a way that would be less easily accessible in a one-to-one
interview. Nevertheless in some cases the one-to-one interview was chosen as the most appropriate
method due to small numbers of participants.
Taking into consideration the need to guarantee validity and reliability in the collection of qualitative
data, the focus group discussions were analyzed in a continuous way, giving feedback to the participants
for additional comments. The questions were open-ended, neutral, sensitive and well understood by the
participants. All focus group interviews were recorded and transcribed verbatim.
Participants received an explanation of the purpose and aim of the study, and those who agreed to
participate were asked to provide verbal consent. No personal identity information was documented and
participants were informed that they had the right to withdraw from the study whenever they wished.
The focus group interviews were completed between 2012 and 2013.
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3. Part A: Survey Results
Anastasia Lykou, EiriniSereti, Pania Karnaki & Agoritsa Baka
3.1 Demographic characteristics The sample consists of 5165 health care workers from 36 countries (64 respondents did not
declare country of employment) who completed the online survey. The countries which have
been taken into account for this analysis are those which have produced more than 20
questionnaires. As shown in Table 1 and Figure 1, 13 countries have been included with a total
of 5058 questionnaires. Analysis was conducted after adjusting (weighting) the sample.
Table1: Distribution by country
Country of employment No. of
questionnaires
%
Sweden 2931 56,75
Greece 553 10,71
Finland 299 5,79
Italy 248 4,80
Germany 228 4,41
Malta 179 3,47
Lithuania 175 3,39
Romania 110 2,13
Slovenia 99 1,92
Spain 93 1,80
Poland 62 1,20
UK 59 1,14
Cyprus 22 0,43
Switzerland 5 0,10
Bulgaria 4 0,08
Hungary 4 0,08
Bhutan 3 0,06
Ireland 3 0,06
Norway 3 0,06
Belgium 2 0,04
Croatia 2 0,04
Netherlands 2 0,04
Slovakia 2 0,04
Argentina 1 0,02
Austria 1 0,02
CzechRepublic 1 0,02
Denmark 1 0,02
Guinea 1 0,02
Iceland 1 0,02
Latvia 1 0,02
FYROM 1 0,02
Portugal 1 0,02
SaudiArabia 1 0,02
Serbia 1 0,02
Turkey 1 0,02
US 1 0,02
Missing 64 1,24
Total 5165 100,00
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Figure1: Distribution by country
The majority of respondents are females (80.7%, Figure 2) and the distribution of their age is
displayed in Figure 3. The majority of participants (96.0%) are between 25 and 64 years old.
Figure 2: Distribution of the respondents by gender
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Figure 3: Distribution of the respondents in terms of their age
Most of the participants have completed a postgraduate degree (61.8%), while a significant
number have received vocational training (18.7%) or academic degree (12.9%) as shown in
Figure 4.
Figure 4: Distribution of the respondents by educational level
The respondents’ current profession is presented specifically for all categories in Table 2 and
generally in Figure 5. The majority of respondents (42.7%) are nurses, 32.8% allied health
professionals and 24.6% medical doctors.
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Table 2: Distribution according to current profession (specific categories)
Frequency Percent
ValidPerce
nt
Pediatricspecialtyorsubspecialty 111 2,1 2,3
Surgicalspecialtyorsubspecialty 126 2,4 2,6
Internal medicine specialty or
subspecialty
142 2,7 2,9
General Practice, family medicine
or equivalent
317 6,1 6,5
Laboratory 53 1,0 1,1
Medicaldoctor_Other 454 8,8 9,3
Hospitalnurse 498 9,6 10,2
Emergency Department nurse
(A&E)
88 1,7 1,8
Infectioncontrolnurse 101 2,0 2,1
Public healthnurse 230 4,5 4,7
Midwife or maternal health nurse 89 1,7 1,8
Maternal health / child health or
school health nurse
148 2,9 3,0
Primaryhealthcarenurse 317 6,1 6,5
Nurse in other settings (nursing
home, outpatient clinic)
264 5,1 5,4
Nurse_other 354 6,9 7,2
Pharmacist 31 ,6 ,6
Dieticians 1 ,0 ,0
Physical, Occupational,
RespiratoryTherapists
146 2,8 3,0
DentalHygienists 23 ,4 ,5
Socialworkers 48 ,9 1,0
Psychologists 57 1,1 1,2
Hospitalepidemiologists 29 ,6 ,6
Ambulancepersonnel 27 ,5 ,6
LaboratoryTechnicians 45 ,9 ,9
Assistants / Aides (e.g. home
health aides, orderlies, attendants)
353 6,8 7,2
Administrative health care service
personnel
196 3,8 4,0
Nonclinical Support personnel of
health care facilities (Food
services, maintenance,
housekeeping/other technical
support, janitors)
36 ,7 ,7
Allied Health Professionals_Other 614 11,9 12,5
Missing 267 5,2
Total 5165 100,00
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Figure 5: Distribution of the respondents by their current profession (general categories)
Figures 6 and 7 display the sector of work and years of experience in current profession. A large
number of participants work in public regional/community hospitals (27.8%), in primary health
care centers (23.4%) and in public tertiary/university hospitals (11.8%). Two-thirds of cases
have more than 10 years’ experience in their current profession (66.7%), 25.2% 2 to 10 years
and 8.0% less than 2 years.
Figure 6: Distribution of the respondents by setting of work
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Figure 7: Distribution of the respondents in terms of their experience in current profession
Explanatory Note - sample adjustment In view of the large number of questionnaires from Sweden compared to the other countries,
and the general asymmetry in the distribution among countries, we choose to adjust the sample
using weights in order to correctly represent the population. We used the following procedure:
We obtained from WHO database the number of Health Care workers, distributed by
country and profession category (WHO reports data for 4 categories: physicians, nurses,
dentists, pharmacists) (the latest available data covering all countries were those of 2009).
Countries having less than 20 responses, as well as questionnaires in which the country is
missing, were omitted from the adjusted sample (in total were omitted 107 questionnaires)
We calculated the observed sample weights by country within each profession.
We calculated the weights based in WHO data by country within each profession.
By dividing the WHO weights with those of the observed sample, we obtained the
frequencies used to weight each observation. In this way, for each profession, the
distribution by country of the weighted sample is the same as in the WHO database.
Important notes:
1. WHO does not report data for other allied health personnel (reports only physicians, nurses,
dentists and pharmacists). Thus, the country weights used for other allied health personnel
and those who did not declare profession category (i.e. missing cases) are calculated based
on the sum of medical doctors, nurses, dentists and pharmaceutical personnel for each
country that are reported by WHO. Thus we assume that these are proportional for each
country to the total of other health professionals (i.e. a country with many physicians and
nurses is expected to have also large allied health personnel).
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2. The above methodology weights the sample by country, to correspond to that of WHO, but
not by profession (i.e. we cannot use the joint distribution, but the marginal), since WHO
does not report the share of the other allied health professionals.
Figures 8 and 9 present country of employment before and after adjusting the sample. TablesA-
1 to A-3 display the WHO weights used.
Figure 8: Distribution by country based on the unadjusted sample
Figure 9: Distribution by country based on the adjusted sample (according to WHO 2009 database)
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3.2 Vaccination behavior
3.2.1. Personal view about vaccines
We asked respondents about their views on the importance of vaccines asking them to agree or
disagree with the following statements: (1) I believe vaccines are important for reducing or
eliminating serious diseases (2) I believe that vaccines are useful in particular settings for
example in the developing world (3) Not sure (4) I believe in challenging natural immunity by
contracting the disease rather than getting vaccinated (5) I don't believe in vaccinations, I
believe that they do more harm than good
Responses were analyzed by country, age, current profession and years in current profession.
The vast majority of respondents believe that vaccines are important for reducing or
eliminating serious diseases (86.1%), while only 7.1% feels that vaccines are useful in
particular settings, 2.4% prefers challenging natural immunity by contracting the disease rather
than getting vaccinated, 2.4% do not believe in vaccines and considers vaccinations harmful
and 2.1% is not sure about the role of vaccinations (Figure 10).
Figure 10: Personal view about vaccination
Analysis by country is shown in Figure 11. As is seen in all countries except Slovenia, the
majority of the health care workers believe that vaccines are important for reducing or
eliminating serious diseases (the corresponding percentages are above 77.0%).In Slovenia
however the majority (55.6%) of respondents believe vaccinations do more harm than good.
(The percentages are displayed analytically in Table A-4).
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Figure 11: Personal view about vaccination by country
Figure 12 depicts participants’ view about vaccination in terms of their current profession. It
turns out that participants’ views about vaccines differ among the categories of the current
profession as shown in the corresponding statistical test (Pearson χ2 = 201.3, p-value < 0.001,
Table A-5). Particularly, physicians believe in higher percentages that vaccines are important
for reducing or eliminating serious diseases (96.3% versus 81% for nurses and 83.1% for allied
health professionals), while only a 1.7% believes that vaccines are useful in particular settings
(versus 9.5% for nurses and 9.7% for allied health professionals). 1.3% of medical doctors does
not believe in vaccinations and feel that they do more harm than good (versus 7.6% for nurses
and 3.1% for allied health professionals).
Figure 12: Personal view about vaccination by their current profession
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The number of age groups was reduced to achieve a better presentation and understanding of
findings. Figure 13 shows that the majority of respondents of each age group believe that
vaccines are important for reducing or eliminating serious diseases. In particular, 85.9% of
respondents aged 18 to 34 years, 83.6% of those aged 35 to 44, and 87.0% of those aged 45 to
54 and 88.1% of those over 55 years old believe that vaccines are important. However, a
considerable percentage of participants believe that vaccines are useful in particular settings
(6.7% for the age group of 18-34 years, 9.4% for 35-44 years and 8.1% for 45-54 years). Views
about vaccines are slightly different for older respondents. More specifically, 5.4% of
respondents aged 55 years and over believe in challenging natural immunity by contracting the
disease rather than getting vaccinated, while the corresponding percentage of people 18 to 34
years is 1.2%, 35 to 44 years is 1.9% and 45 to 54 years is 1.7%. On the other hand, younger
respondents seem to have a worse opinion about vaccinations compared to older people, as
4.8% aged 18 to 34 years, 3.6% of 35 to 44 years believe that vaccines do more harm than
good. The corresponding percentages for ages between 45 to 54 and older than 55 years are
0.7% and 0.6% of 55 respectively. The differences of the respondents’ views among the age
groups are found to be statistically significant (Pearson χ2 = 167.7, p-value < 0.001).
Figure 13: Personal view about vaccination by age group
Figure 14 shows the HCWs opinions about vaccination by years of experience in their current
profession. The majority of participants believe that vaccination is important regardless of years
of experience.
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Figure 14: Personal view about vaccines by years of experience
3.2.2. Diseases believed by respondents to be more at risk of contracting or
transmitting to patients or family Health care workers were asked about the diseases they believe they are more at risk of
contracting due to the nature of their workortransmitting to patients and family.In these two
types of questionsrespondents could choose more than one answer. Respondents declared that
Influenza (86.4%), Hepatitis B (71.9%) and Tuberculosis (59.1%) are among the diseases
that are more at risk of being contracted at their work (Figure 15).
Figure 15: Diseases that are believed by the respondents to be more at risk of contracting
The percentage of the health care workers who believe that Influenza, Tuberculosis and
Hepatitis B are among the most dangerous diseases for transmitting to patients and family
are 91.9%, 42.0% and 17.9% as shown in Figure 16.
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Figure 16: Diseases that are believed by the respondents to be more at risk of transmitting to patients and family
3.2.3. Immunization against Vaccine Preventable Diseases (VPD) Respondents were asked whether they were required to prove immunity before they began
work. Figure 17 shows that more than half of the workers (52.1%) did not need to prove
immunity against vaccine preventable diseases.
Figure 17: Requirement for immunization against VPDs
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Of those who were asked to prove immunity, 93.6% had to prove immunity against Hepatitis B,
40.6% against Rubella, 39.2% against measles and 36.6% against Mumps (Figure 18).
Figure 18: Percentages of respondents having to prove immunity against VPDs (based on those who declared that had to prove immunity)
Percentages of respondents having to prove immunity are presented separately for each country
in Figure 19.The majority of health care workers from all countries do not need to prove
immunity against vaccine preventable diseases except Germany, Italy, Malta, Slovenia and
UK. Thus the relation between country and requirement for immunity is statistically significant
(Pearson χ2 = 473.9, p-value < 0.001, Table A-5).
Figure 19: Requirement for immunization against VPDs by country
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The requirement to prove immunity before starting work is shown for each work sector in
Figure 20 (percentages are given analytically in Table A-6). The majority of the respondents
who work in academia, industry or private practice do not have to prove immunity.
Respondents who work in the remaining wok sectors have to prove immunity more frequently
(however, the percentages are between 41.9% and 56.9%). It turns out that the frequency of
proving immunity differs significantly across the work sectors, as shows the corresponding
statistical test (Pearson χ2= 105.4, p-value < 0.001).
Figure 20: Requirement for immunization against VPDs by work sector
3.2.4. Yearly vaccination against seasonal influenza Most health care workers (65.1%) are not required by their employer to receive the seasonal
influenza vaccine each year (Figure 21). Respondents who receive the seasonal influenza
vaccine every year are presented with respect to their current profession, country of
employment and work sector in Figures 22, 23 and 24. The corresponding percentages are
displayed analytically in Tables A-7 and A-8.
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Figure 21: Percentage of respondents who are required to receive the seasonal influenza vaccine every year
As is seen in Figure 22, nurses reported that they are required to receive the seasonal
influenza vaccine in 37.0% of the cases, which is more frequent than the corresponding
frequencies for medical doctors (32.4%) and allied professionals (33.7%). Thus, there is a
significant difference between current profession and the requirement to receive the seasonal
influenza vaccine (Pearson χ2 = 8.1, p-value = 0.017).
Figure 22: Percentage of respondents who are required to receive the seasonal influenza vaccine every year by their current profession
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The majority of respondents as seen in Figure 23 (and Table A-7) (more than 77.8%) in
Sweden, Greece, Slovenia, Spain, Poland, UK and Cyprus are not required to receive the
seasonal influenza vaccine. The corresponding percentages for health care workers from
Finland, Italy, Malta and Lithuania are lower (between 53.5% and 63.0%). Most of the
respondents from Germany (51.9%) and Romania (62.8%) do have to receive the seasonal
influenza vaccine every year.
Figure 23: Respondents required to receive the seasonal influenza vaccine each year by country
Most of the health care workers in public tertiary or university hospital (73.4%), academia
(76.4%), industry (74.5%) and other settings (76.2%) as is seen in Figure 24 are not required
to receive the seasonal influenza vaccine every year. The health care workers in all the other
work sectors are required to receive this vaccine more frequently; however, the
corresponding percentages are still less than 50%. The requirement of the health care workers
to receive this vaccine differs significantly among the categories of the work sector as shows
the corresponding statistical test (Pearson χ2 = 148.1, p-value < 0.001, Table A-8).
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Figure 24: Respondents required to receive the seasonal influenza vaccine every year by work sector
3.2.5. Vaccination in the last 10 years Health care workers were asked about the vaccination they received in the last years and the
reasons for doing or not doing so. Hepatitis B, Td or Tdap and seasonal influenza flu are
among the most frequent vaccines respondents received over the last 10 years. Findings for
each of the vaccines are shown in Figure 25 and they are based only on those who remember
having received them.
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Figure 25: Percentage of respondents who have received any of the vaccines in the last 10 years (based on those who remember)
In the following section findings are summarized separately for each vaccine with respect to
country of employment and current profession.
Seasonal Influenza (flu) vaccine
As shown in Figure 26, the UK and Finland have the highest percentage of respondents who
have received seasonal influenza vaccines (83.5% and 80.6% respectively) in the last 10
years. The corresponding percentages for Poland, Malta and Romania are 76.8%, 75.0% and
72.2%. It turns out that respondents from Spain (63.6%), Germany (59.3%), Lithuania
(55.9%), Italy (54.0%) and Greece (52.5%) have received less frequently such a vaccination.
The majority of health care workers from Sweden, Cyprus and Slovenia have not received the
seasonal influenza vaccination. The detailed percentages are presented analytically in Table A-
9.
Figure 26: Respondents having received the seasonal influenza vaccine by country
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Figure 27 displays the frequency of seasonal influenza vaccine with respect to current
profession. Medical doctors receive the seasonal influenza vaccine more frequently (76.7%)
than nurses (62.0%) and allied health professionals (56.3%). The difference in these
percentages is found to be significant according to the corresponding statistical test (Pearson χ2
= 97.5, p-value < 0.001).
Figure 27: Percentage of respondents who have received the seasonal influenza vaccine by current profession
Health care workers were also asked to declare the reasons for receiving or not receiving this
vaccine. The majority (60.0%) of those who have received the vaccine did so, because they
believed in the protection that it can offer (Figure 28).
Figure 28: Reasons for receiving the seasonal influenza (flu) vaccine (based in those who declared a reason for receiving)
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No great differences concerning the reasons for receiving this vaccine are observed between
different professions (Figure 29).
Figure 29: Reasons for receiving the seasonal influenza (flu) vaccine by current profession (based in those who declared a reason for receiving)
More than 30% percent of nurses and allied health professionals who did not receive the
seasonal influenza vaccine believe more in natural immunity rather than in vaccination,
whereas, the corresponding percentage for medical doctors is 18.1% (Figures 30 and 31).
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Figure 30: Reasons for not receiving the Seasonal Influenza (flu) vaccine (based on those who declared a reason for not receiving)
Figure 31: Reasons for not receiving the Seasonal Influenza (flu) vaccine by current profession (based on those who declared a reason for not receiving)
Pandemic Influenza (swine flu) vaccine
The majority of the respondents from Finland (88.9%), Sweden (83.1%), Malta (75.0%),
Romania (62.7%) and the UK (59.3%) have received the pandemic influenza vaccine. Most of
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the respondents from the remaining countries have not received such vaccination (Figure 32
and Table A-10).
Figure 32: Percentage of respondents who have received the pandemic influenza vaccine by country
Most of the medical doctors (56.5%) have received the pandemic influenza vaccine, whereas,
most of the nurses (64.6%) and the allied health professionals (57.0%) have not received it (Figure 33). It turns out that the frequency of receiving the pandemic influenza vaccine differs
significantly among the categories of the current profession of the respondents (Pearson χ2 =
108.3, p-value < 0.001).
Figure 33: Percentage of respondents who have received the pandemic influenza vaccine by current profession
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Respondents who have received this vaccine due to the protection that they believe it offers in
the 58.5% of the cases (particularly, this reason was selected by the 67.4% of medical doctors,
55.2% of nurses and 56.3% of allied health professionals, Figures 34 and 35).
Figure 34: Reasons for receiving the Pandemic influenza (swine flu) vaccine (based on those who declared a reason for receiving)
Figure 35: Reasons for receiving the Pandemic influenza (swine flu) vaccine by current profession (based on those who declared a reason for receiving)
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Most of the health care workers have not received this vaccine because they believe that they
are not at risk (28.0%) or they are concerned about vaccines side effects (24.4%). Nurses and
allied professional (31.0% and 21.7%) seem to worry more about vaccines side effects than
medical doctors (14.7%). The results are given analytically in Figures 36 and 37.
Figure 36: Reasons for not receiving the Pandemic influenza (swine flu) vaccine (based on those who declared a reason for not receiving)
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Figure 37: Reasons for not receiving the Pandemic influenza (swine flu) vaccine by current profession (based on those who declared a reason for not receiving)
MMR (mumps-measles-rubella vaccine)
The majority of the respondents from Finland (54.1%) and Germany (60.8%) have received
MMR vaccination. The percentage of health care workers who have received MMR
vaccination in Malta is 50%, in Greece 43.3%, in Spain 41.6%, in the UK 39.3% and in
Sweden 28.4%. The corresponding percentages for the remaining countries are much lower
(less than 14.4%) as shown in Figure 38 and Table A-11.
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Figure 38: Percentage of respondents who have received the MMR vaccine by country
No great differences are observed among the current profession of the respondents and the
frequency that they receive MMR vaccination (Figure 39). This is also verified by the
corresponding statistical test (Pearson χ2 = 1.5, p-value = 0.477).
Figure 39: Percentage of respondents who have received the MMR vaccine by current profession
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Almost 67% of the respondents have received the MMR because they believe in the protection
it offers (Figure 40).
Figure 40: Reasons for receiving the MMR (based on those who declared a reason for receiving)
Around 42% of the medical doctors have received this vaccine to avoid transmitting the disease
to patients, whereas, the corresponding percentages for nurses and allied professionals are
28.3% and 8.7% respectively. Besides that, almost 20% of the medical doctors declared that
they have been vaccinated because they were required by their employer, though, less than 5%
of the nurses and allied professional got vaccinated for this reason (Figure 41).
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Figure 41: Reasons for receiving the MMR by current profession (based on those who declared a reason for receiving)
Most of the respondents who have not received this vaccine because they have contracted the
disease in the past or have already received this vaccination (Figures 42 and 43).
Figure 42: Reasons for not receiving the MMR (based on those who declared a reason for not receiving)
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Figure 43: Reasons for not receiving the MMR by current profession(based on those who declared a reason for not receiving)
Varicella (chickenpox) vaccine
The majority of respondents from all the countries have not received the varicella vaccine (Figure 44, the percentages are displayed in Table A-12).
Figure 44: Percentage of respondents who have received the varicella (chickenpox) vaccine by country
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The percentages of nurses and allied professionals who have received the varicella vaccine are
13.4% and 13.0% respectively; slightly higher than the percentage for medical doctors, which is
11.0% (Figure 45). The percentages of receiving this vaccine differ significantly among the
categories of the current profession, as shows the corresponding statistical test (Pearson χ2 =
221.9, p-value < 0.001).
Figure 45: Percentage of respondents who have received the varicella (chickenpox) vaccine by current profession
The majority of those who have received this vaccine reported that they did so because they
believe in the protection that it offers. Nurses declared that this was the reason that they got this
vaccine in the 79.3% of the cases, medical doctors in the 57.3% and allied health professional in
the 39.0% (Figures 46 and 47).
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Figure 46: Reasons for receiving the varicella (chickenpox) vaccine (based on those who declared a reason for receiving)
Figure 47: Reasons for receiving the varicella (chickenpox) vaccine by current profession (based on those who declared a reason for receiving)
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The great majority of the respondents have not received the varicella vaccine because they have
received it in the past (Figures 48 and 49).
Figure 48: Reasons for not receiving the varicella (chickenpox) vaccine (based on those who declared a reason for not receiving)
Figure 49: Reasons for not receiving the varicella (chickenpox) vaccine by current profession (based on those who declared a reason for not receiving)
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Hepatitis B vaccine
The majority of the respondents in all countries have received the hepatitis B vaccine, apart
from Lithuania, where 45.8% of the health care workers have received it (Figure 50 and Table
1-13).
Figure 50: Percentage of respondents who have received the Hepatitis B vaccine by country
The majority of the respondents from all the categories of current profession have received this
vaccine. The relation between frequency of receiving this vaccine and the current profession is
found to be statistically significant (Pearson χ2 = 27.5, p-value < 0.001). In particular, medical
doctors receive the hepatitis B vaccine more frequently (82.7%) than nurses (79.3%) and allied
health professionals (72.4%) as shown in Figure 51.
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Figure 51: Percentage of respondents who have received the Hepatitis B vaccine by current profession
Concerning the reasons for receiving this vaccine, most of the respondents declared that they
did so because they believe in the protection it offers or they were at risk of acquiring or
contracting the disease (Figure 52). More than the half doctors and nurses who have received
the Hepatitis B vaccine, did so because they believe in the protection it offers (Figure 53).
Figure 52: Reasons for receiving the Hepatitis B vaccine (based on those who declared a reason for receiving)
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Figure 53: Reasons for receiving the Hepatitis B vaccine by current profession (based on those who declared a reason for receiving)
Most of the respondents have not received this vaccine because they have already received it in
the past (Figure 54). Figure 54: Reasons for not receiving the Hepatitis B vaccine (based on those who declared a reason for not receiving)
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More than the half doctors and nurses who have not received the vaccine in the last 10 years is
because they have already received it in the past (Figures 55). Around 37% of the allied health
professionals, who have not received it, declared that they did so because they believe that they
are not at risk. The corresponding percentage for medical doctors is lower (20.4%) and for
nurses very low (3.7%).
Figure 55: Reasons for not receiving the Hepatitis B vaccine by current profession (based on those who declared a reason for not receiving)
Td (adult tetanus vaccine) or Tdap (adult tetanus, diphtheria and pertussis vaccine)
The highest percentages of health care workers who have received the Td or Tdap vaccine
are in Finland (97.9%) and Germany (91.3%) as shown in Figure 56 and Table A-14. The
corresponding percentages for Spain, Greece, Malta, UK, Italy and Sweden are lower but still
high (between 75.4% and 59.1%). Lithuania, Poland, Romania and Slovenia have the lowest
percentage of respondents who have received the Td or Tdap vaccine (below 50%).
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Figure 56: Percentage of respondents who have received the Td or Tdap vaccine by country
No great differences are observed between the frequency of Td and Tdap vaccination and the
current profession of respondents (Figure 57). The majority of all the health care workers have
received such a vaccination.
Figure 57: Percentage of respondents who have received the Td or Tdap vaccine by current profession
The majority of respondents who have received the Td or Tdap vaccine did so because they
believe that it can protect them (Figures 58 and 59).
41
Figure 58: Reasons for receiving the Td orTdap (based on those who declared a reason for receiving)
Figure 59: Reasons for receiving the Td or Tdap by current profession (based on those who declared a reason for receiving)
42
About half of the respondents who have not received this vaccine the last 10 years claimed that
they have already received it in the past (Figure 60). Similar are the percentages when they are
presented according to their current profession (Figure 61). However, 20% percent of the
doctors who have not received such vaccination, did so because they don’t believe that they are
at risk; whereas, the corresponding percentage for nurses is 4.5% and for allied professional
6.6%.
43
Figure 60: Reasons for not receiving the Td or Tdap (based on those who declared a reason for not receiving)
Figure 61: Reasons for not receiving the Td or Tdap by current profession (based on those who declared a reason for not receiving)
44
3.2.6. Views about mandatory vaccination against VPDs
Most of the respondents have a positive view about VPDs being mandatory for HCWs
who come in regular contact with patients. About 62% gave positive answers (Figure 62).
Figure 62: Views about mandatory vaccination for HCW
Respondents’ views about mandatory vaccination differ significantly among the categories
of their current profession as verified by the corresponding statistical test (Pearson χ2 = 257.9,
p-value < 0.001). In particular, the majority of medical doctors (77.3%) believe that vaccination
should be mandatory, whereas, the corresponding percentages are lower for nurses and allied
categories (Figure 63).
45
Figure 63: Views about mandatory vaccination by current profession
3.3 Logistic regression for the probability of not believing in
vaccination In order to explore the characteristics of health care workers who do not hold a positive view
towards vaccination logistic regression was performed, (the dependent variable takes the value
1 for the last two categories of question 8, and zero otherwise), controlling for participants’
characteristics.
The logistic regression model is presented in Table 3. It turns out that health workers from Italy
and Slovenia have higher probability of not believing in vaccinations in relation to those from
Sweden (OR=5.01, p-value=0.001 for Italy and OR=191.70, p-value<0.001 for Slovenia,
respectively). On the other hand, health workers from Finland have less probability of not
believing in vaccination in relation to those from Sweden (OR=0.14. p-value=0.018). There
were no cases of health workers form the UK or Cyprus not believing in vaccination.
The model is also adjusted for gender and age, which do not seem to affect the probability of
believing in vaccination.
In terms of current profession, nurses and allied health professional seem to have higher
probability of not believing in vaccination than the medical doctors. In particular, the odds of
not believing in vaccination the nurses are about 7 times the odds for medical doctors
(OR=7.45, p-value<0.001) given that they have the same characteristics in the remaining
variables. The odds of not believing in vaccination the allied health professionals are almost 3
times the corresponding odds for medical doctors (OR=2.92, p-value=0.004) given that they
have the same characteristics in the other variables.
Concerning the work sector, those working in public health hospitals, long term care facilities
and public health institutes have lower probability of not believing in vaccination than those
who are working in other settings. However, those working in specialty clinics, academia and
46
industry seem to not believe in vaccination in higher percentages than those working in other
settings.
It seems that participants with an academic degree are 4 times as likely not to believe in
vaccination in relation to those with vocational training (OR=4.24, p-value<0.001).
Table 3: Logistic regression analysis for the probability of not believing in vaccination
p-value OR 95% C.I. for OR
Lower Upper
Country of employment
(reference level: Sweden) <0.001
Greece 0.951 0.95 0.21 4.29
Finland 0.018 0.14 0.03 0.72
Italy 0.001 5.01 1.87 13.46
Germany 0.683 1.24 0.45 3.41
Malta 0.980 0.93 0.003 269.77
Lithuania 0.226 0.26 0.03 2.32
Romania 0.943 0.95 0.23 3.91
Slovenia <0.001 191.70 43.02 854.21
Spain 0.765 0.82 0.23 2.96
Poland 0.414 0.60 0.18 2.02
UK . . . .
Cyprus . . . .
Current profession
(ref. level: Medical doctors) <0.001
Nurses <0.001 7.45 3.66 15.15
Allied professionals 0.004 2.92 1.40 6.08
Setting of work (reference level Other setting)
<0.001
Public regional /
Community Hospital <0.001 0.30 0.17 0.53
Private regional /
Community Hospital 0.489 1.31 0.61 2.83
Public tertiary /
UniversityHospital 0.268 0.60 0.24 1.49
Specialty clinics 0.001 2.75 1.53 4.97
Long term care facilities 0.043 0.37 0.14 0.97
Primary Health Care Center 0.529 1.23 0.65 2.30
Privatepractice 0.084 2.18 0.90 5.26
Public Health Institute or other governmental organization
<0.001 0.22 0.10 0.48
Academia <0.001 6.30 2.42 16.40
Industry <0.001 10.48 3.62 30.36
Level of education
(reference level: vocational training)
<0.001
Primary school 0.825 1.90 0.01 572.37
Secondary school 0.486 1.37 0.56 3.34
47
Academic degree <0.001 4.24 2.22 8.12
Postgraduate degree 0.975 1.01 0.56 1.83
No. of observations after excluding missing cases for all variables: 4687,
Nagelkerke R2: 0.385, Correctly classified: 95.5%
3.4 Survey conclusions The main conclusions as derived from the survey analysis are presented below:
The majority of the health care workers believe that vaccines are important for reducing or
eliminating serious diseases (the corresponding percentages are above 77.0%).In Slovenia
however the majority (55.6%) of respondents believe vaccinations do more harm than good.
Physicians believe in higher percentages that vaccines are important for reducing or eliminating
serious diseases (96.3% versus 81% for nurses and 83.1% for allied health professionals)
Age seems to affect participants’ opinion of vaccines with younger people having a worse
opinion
Respondents declared that Influenza (86.4%), Hepatitis B (71.9%) and Tuberculosis (59.1%) are
among the diseases that are more at risk of being contracted at their work
The percentage of health care workers who believe that Influenza, Tuberculosis and Hepatitis B
are among the most dangerous diseases for transmitting to patients and family are 91.9%, 42.0%
and 17.9%
More than half of the workers (52.1%) did not need to prove immunity against vaccine
preventable diseases.
Of those who were asked to prove immunity, 93.6% had to prove immunity against Hepatitis B,
40.6% against Rubella, 39.2% against measles and 36.6% against Mumps
The majority of health care workers from all countries do not need to prove immunity against
vaccine preventable diseases except Germany, Italy, Malta, Slovenia and the UK
The majority of respondents who work in academia, industry or in private practice do not have
to prove immunity. Respondents who work in the remaining work sectors have to prove
immunity more frequently
Nurses reported that they are required to receive the seasonal influenza vaccine in 37.0% of the
cases, which is more frequent than the corresponding frequencies for medical doctors (32.4%)
and allied professionals (33.7%).
The majority of respondents (more than 77.8%) in Sweden, Greece, Slovenia, Spain, Poland, the
UK and Cyprus are not required to receive the seasonal influenza vaccine. The corresponding
percentages for health care workers from Finland, Italy, Malta and Lithuania are lower (between
53.5% and 63.0%). Most of the respondents from Germany (51.9%) and Romania (62.8%) do
have to receive the seasonal influenza vaccine every year.
Most of the health care workers in public tertiary or university hospital (73.4%), academia
(76.4%), industry (74.5%) and other settings (76.2%) are not required to receive the seasonal
influenza vaccine every year. Health care workers in all the other work sectors are required to
receive this vaccine more frequently; however, the corresponding percentages are still less than
50%.
The UK and Finland have the highest percentage of respondents who have received seasonal
influenza vaccines (83.5% and 80.6% respectively) in the last 10 years. The corresponding
percentages for Poland, Malta and Romania are 76.8%, 75.0% and 72.2%. Respondents from
Spain (63.6%), Germany (59.3%), Lithuania (55.9%), Italy (54.0%) and Greece (52.5%) have
48
received less frequently such a vaccination. The majority of health care workers from Sweden,
Cyprus and Slovenia have not received the seasonal influenza vaccination
Medical doctors receive the seasonal influenza vaccine more frequently (76.7%) than nurses
(62.0%) and allied health professionals (56.3%).
More than 30% percent of nurses and allied health professionals who did not receive the
seasonal influenza vaccine believe more in natural immunity rather than in vaccination, whereas,
the corresponding percentage for medical doctors is 18.1%
The majority of respondents from Finland (88.9%), Sweden (83.1%), Malta (75.0%), Romania
(62.7%) and the UK (59.3%) have received the pandemic influenza vaccine. Most of the
respondents from the remaining countries have not received such vaccination
Most of the medical doctors (56.5%) have received the pandemic influenza vaccine, whereas,
most of the nurses (64.6%) and the allied health professionals (57.0%) have not received it
The majority of respondents from Finland (54.1%) and Germany (60.8%) have received the
MMR vaccination. The percentage of health care workers who have received the MMR
vaccination in Malta is 50%, in Greece 43.3%, in Spain 41.6%, in the UK 39.3% and in Sweden
28.4%.
Almost 67% of the respondents have received the MMR vaccination because they believe in the
protection it offers. Most of the respondents who have not received this vaccine because they
have contracted the disease in the past or have already received this vaccination
The majority of respondents from all countries have not received the varicella vaccine in the last
10 years. The majority of those who have received this vaccine reported that they did so because
they believe in the protection that it offers while those who haven’t mentioned they had received
it in the past.
The majority of respondents in all countries have received the hepatitis B vaccine, apart from
Lithuania, where only 45.8% of the health care workers have received it. Concerning the reasons
for receiving this vaccine, most of the respondents declared that they did so because they believe
in the protection it offers or they were at risk of acquiring or contracting the disease. Most of the
respondents have not received this vaccine in the last 10 years because they have already
received it in the past. Around 37% of the allied health professionals, who have not received it,
declared that they did so because they believe that they are not at risk. The corresponding
percentage for medical doctors is lower (20.4%) and for nurses very low (3.7%).
The highest percentages of health care workers who have received the Td or Tdap vaccine are in
Finland (97.9%) and Germany (91.3%). Percentages are lower for other countries but still
overall high. Most respondents said they believed in the protection of the vaccine while those
who were not vaccinated mentioned that they did not believe they were at risk of contracting the
disease
Most of the respondents have a positive view about VPDs being mandatory for HCWs who
come in regular contact with patients.
The majority of medical doctors (77.3%) believe that vaccination should be mandatory, whereas,
the corresponding percentages are lower for nurses and other allied categories
Health workers from Italy and Slovenia have higher probability of not believing in vaccinations
in relation to those from Sweden (OR=5.01, p-value=0.001 for Italy and OR=191.70, p-
value<0.001 for Slovenia, respectively). On the other hand, health workers from Finland have
less probability of not believing in vaccination in relation to those from Sweden (OR=0.14. p-
value=0.018). There were no cases of health workers form the UK or Cyprus not believing in
vaccination.
In terms of current profession, nurses and allied health professional seem to have higher
probability of not believing in vaccination than medical doctors
49
Those working in public health hospitals, long term care facilities and public health institutes
have lower probability of not believing in vaccination than those who are working in other
settings. However, those working in specialty clinics, academia and industry seem to not believe
in vaccination in higher percentages than those working in other settings.
It seems that participants with an academic degree are 4 times as likely not to believe in
vaccination in relation to those with vocational training (OR=4.24, p-value<0.001).
50
Appendix A: Survey Table A-1: Observed weights
Table A-2: WHO weights
Observed sample weights
by country within each
profession
Medical
doctor
Nurse &
assistant Dentists
Pharmace
utical
personnel
Other allied
professionals
Sweden 39,12% 60,46% 46,67% 82,61% 69,17%
Greece 6,29% 15,98% 10,00% 13,04% 6,15%
Finland 3,15% 8,53% 3,33% 4,35% 3,82%
Italy 4,59% 6,29% 2,97%
Germany 12,16% 1,20% 16,67% 3,61%
Malta 9,78% 1,70% 3,33% 1,56%
Lithuania 5,61% 2,40% 3,61%
Romania 6,63% 0,17% 1,98%
Slovenia 6,21% 0,29% 13,33% 1,06%
Spain 3,83% 0,87% 6,67% 1,77%
Poland 0,51% 0,58% 2,97%
UK 1,62% 1,12% 0,92%
Cyprus 0,51% 0,41% 0,42%
Sum of weights by profession100,00% 100,00% 100,00% 100,00% 100,00%
WHO weigths by country
within each profession
Medical
doctor
Nurse &
assistant Dentists
Pharmace
utical
personnel
Sum (for allied
professionals)
Sweden 3,21% 3,84% 3,57% 2,77% 3,61%
Greece 6,27% 1,45% 7,07% 3,90% 3,07%
Finland 1,40% 4,50% 1,92% 2,32% 3,47%
Italy 18,44% 13,73% 14,87% 21,04% 15,39%
Germany 27,07% 32,56% 30,75% 19,77% 30,35%
Malta 0,11% 0,10% 0,09% 0,09% 0,10%
Lithuania 1,11% 0,86% 1,12% 1,03% 0,94%
Romania 4,41% 4,46% 5,95% 4,71% 4,53%
Slovenia 0,45% 0,58% 0,59% 0,42% 0,54%
Spain 14,78% 7,85% 12,78% 18,54% 10,44%
Poland 7,53% 7,90% 5,82% 9,60% 7,80%
UK 15,02% 22,05% 15,10% 15,73% 19,59%
Cyprus 0,21% 0,14% 0,37% 0,08% 0,16%
Sum of weights by profession 100,00% 100,00% 100,00% 100,00% 100,00%
51
Table A-3: Frequency matrix
Table A-4: Personal view about vaccines by country of employment
Country of employment
Which of the following statements do you feel that best reflects your personal view
about vaccines
Total
Important for
reducing or
eliminating
serious
diseases
Useful in
particular
settings for
example in the
developing world
Not sure Challenging
natural
immunity rather
than getting
vaccinated
Do more harm
than good
Sweden 162 (88.5%) 7 (3.8%) 8 (4.4%) 5 (2.7%) 1 (0.5%) 183
Greece 134 (86.5%) 12 (7.7%) 4 (2.6%) 5 (3.2%) 0 155
Finland 166 (94.3%) 6 (3.4%) 1 (0.6%) 2 (1.1%) 1 (0.6%) 176
Italy 606 (79.6%) 69 (9.1%) 11 (1.4%) 36 (4.7%) 39 (5.1%) 761
Germany 1172 (77.8%) 210 (13.9%) 29 (1.9%) 42 (2.8%) 54 (3.6%) 1507
Malta 5 (100.0%) 0 0 0 0 5
Lithuania 42 (87.5%) 1 (2.1%) 3 (6.3%) 1 (2.1%) 1 (2.1%) 48
Romania 188 (84.3%) 1 (0.4%) 30 (13.5%) 4 (1.8%) 0 223
Slovenia 8 (29.6%) 0 1 (3.7%) 3 (11.1%) 15 (55.6%) 27
Spain 485 (94.2%) 0 15 (2.9%) 6 (1.2%) 9 (1.7%) 515
Poland 368 (94.6%) 5 (1.3%) 0 16 (4.1%) 0 389
UK 945 (95.8%) 41 (4.2%) 0 0 0 986
Cyprus 7(87.5%) 1 (12.5%) 0 0 0 8
Total 4288 (86.1%) 353 (7.1%) 102 (2.0%) 120 (2.4%) 120 (2.4%) 4983
Frequency matrix used to
adjust the sample
Medical
doctor
Nurse &
assistant Dentists
Pharmace
utical
Other allied
professionals
Sweden 0,08 0,06 0,08 0,03 0,05
Greece 1,00 0,09 0,71 0,30 0,50
Finland 0,44 0,53 0,58 0,53 0,91
Italy 4,01 2,18 5,18
Germany 2,23 27,11 1,85 8,42
Malta 0,01 0,06 0,03 0,06
Lithuania 0,20 0,36 0,26
Romania 0,66 26,91 2,29
Slovenia 0,07 2,01 0,04 0,51
Spain 3,86 9,03 1,92 5,91
Poland 14,75 13,62 2,63
UK 9,30 19,72 21,31
Cyprus 0,41 0,33 0,38
52
Table A-5: Requirement for immunization against VPDs by work sector
Are you required by your hospital/organization to prove
immunity against any of the following Vaccine Preventable
Disease(s) before you begin to work?
Setting of work No Yes Total
Public regional/community Hospital 458 (48.8%) 480 (51.2%) 938
Private regional/community Hospital 47 (43.1%) 62 (56.9%) 109
Public tertiary/university Hospital 131 (47.1%) 147 (52.9%) 278
Specialty clinics 80 (47.1%) 90 (52.9%) 170
Long term care facilities 76 (44.4%) 95 (55.6%) 171
Primary Health Care Center 339 (46.0%) 398 (54.0%) 737
Private practice 171 (63.6%) 98 (36.4%) 269
Public Health Institute or other
governmental organization
698 (53.3%) 612 (46.7%) 1310
Academia 115 (77.7%) 33 (22.3%) 148
Industry 43 (78.2%) 12 (21.8%) 55
Other setting 390 (58.1%) 281 (41.9%) 671
Total 2548 (52.5%) 2308 (47.5%) 4856
Table A-6: Requirement to receive the seasonal influenza vaccine by country
Are you required by your employer to receive the seasonal
influenza vaccine every year?
Country of employment Yes No Total
Sweden 16 (8.8%) 165 (91.2%) 181
Greece 18 (11.8%) 134 (88.2%) 152
Finland 76 (43.7%) 98 (56.3%) 174
Italy 350 (46.5%) 403 (53.5%) 753
Germany 790 (51.9%) 733 (48.1%) 1523
Malta 2 (40.0%) 3 (60.0%) 5
Lithuania 17 (37.0%) 29 (63.0%) 46
Romania 140 (62.8%) 83 (37.2%) 223
Slovenia 6 (22.2%) 21 (77.8%) 27
Spain 112 (21.7%) 403 (78.3%) 515
Poland 27 (6.9%) 363 (93.1%) 390
UK 168 (17.8%) 778 (82.2%) 946
Cyprus 1 (12.5%) 7 (87.5%) 8
Total 1723 (34.9%) 3220 (65.1%) 4943
53
Table A-7: Requirement to receive the seasonal influenza vaccine by work sector
Are you required by your employer to receive the seasonal influenza vaccine every year?
Setting of work Yes No Total
Public regional/community Hospital 453 (48.7%) 478 (51.3%) 931
Private regional/community Hospital 36 (33.3%) 72 (66.7%) 108
Public tertiary/university Hospital 74 (26.6%) 204 (73.4%) 278
Specialty clinics 73 (42.9%) 97 (57.1%) 170
Long term care facilities 74 (43.5%) 96 (56.5%) 170
Primary Health Care Center 214 (30.9%) 479 (69.1%) 693
Private practice 97 (37.5%) 162 (62.5%) 259
Public Health Institute or other
governmental organization
482 (37.1%) 816 (62.9%) 1298
Academia 35 (23.6%) 113 (76.4%) 148
Industry 14 (25.5%) 41 (74.5%) 55
Other setting 159 (23.8%) 509 (76.2%) 668
Total 1711 (35.8%) 3067 (64.2%) 4778
Table A-8: Seasonal influenza vaccine by country
Seasonal Influenza (flu) vaccine
Country of employment I haven't received I have received Total
Sweden 81 (55.1%) 66 (44.9%) 147
Greece 57 (47.5%) 63 (52.5%) 120
Finland 28 (19.4%) 116 (80.6%) 144
Italy 302 (46.0%) 355 (54.0%) 657
Germany 565 (40.7%) 823 (59.3%) 1388
Malta 1 (25.0%) 3 (75.0%) 4
Lithuania 15 (44.1%) 19 (55.9%) 34
Romania 49 (27.8%) 127 (72.2%) 176
Slovenia 14 (73.7%) 5 (26.3%) 19
Spain 148 (36.4%) 259 (63.6%) 407
Poland 76 (23.2%) 252 (76.8%) 328
UK 138 (16.5%) 699 (83.5%) 837
Cyprus 3 (60.0%) 2 (40.0%) 5
Total 1477 (34.6%) 2789 (65.4%) 4266
54
Table A-9: Pandemic influenza vaccine by country
Pandemic influenza (swine flu) vaccine
Country of employment I haven't received I have received Total
Sweden 24 (16.9%) 118 (83.1%) 142
Greece 67 (63.8%) 38 (36.2%) 105
Finland 15 (11.1%) 120 (88.9%) 135
Italy 354 (67.4%) 171 (32.6%) 525
Germany 874 (67.4%) 422 (32.6%) 1296
Malta 1 (25.0%) 3 (75.0%) 4
Lithuania 18 (81.8%) 4 (18.2%) 22
Romania 59 (37.3%) 99 (62.7%) 158
Slovenia 15 (78.9%) 4 (21.1%) 19
Spain 242 (69.5%) 106 (30.5%) 348
Poland 218 (76.8%) 66 (23.2%) 284
UK 328 (40.7%) 478 (59.3%) 806
Cyprus 4 (80.0%) 1 (20.0%) 5
Total 2219 (57.7%) 1630 (42.3%) 3849
Table A-10: MMR vaccine by country
MMR (mumps-measles-rubella vaccine)
Country of employment I haven't received I have received Total
Sweden 73 (71.6%) 29 (28.4%) 102
Greece 34 (56.7%) 26 (43.3%) 60
Finland 45 (45.9%) 53 (54.1%) 98
Italy 386 (85.6%) 65 (14.4%) 451
Germany 375 (39.2%) 582 (60.8%) 957
Malta 1 (50.0%) 1 (50.0%) 2
Lithuania 12 (85.7%) 2 (14.3%) 14
Romania 134 (93.1%) 10 (6.9%) 144
Slovenia 10 (90.9%) 1 (9.1%) 11
Spain 156 (58.4%) 111 (41.6%) 267
Poland 207 (90.0%) 23 (10.0%) 230
UK 332 (60.7%) 215 (39.3%) 547
Cyprus 0 1 (100.0%) 1
Total 1765 (61.2%) 1119 (38.8%) 2884
55
Table A-11: Varicella vaccine by country
Varicella (chickenpox) vaccine
Country of employment I haven't received I have received Total
Sweden 115 (94.3%) 7 (5.7%) 122
Greece 65 (77.4%) 19 (22.6%) 84
Finland 101 (89.4%) 12 (10.6%) 113
Italy 427 (88.8%) 54 (11.2%) 481
Germany 843 (77.5%) 245 (22.5%) 1088
Malta 2 (100.0%) 0 2
Lithuania 17 (94.4%) 1 (5.6%) 18
Romania 106 (97.2%) 3 (2.8%) 109
Slovenia 14 (100.0%) 0 14
Spain 265 (85.2%) 46 (14.8%) 311
Poland 244 (98.0%) 5 (2.0%) 249
UK 598 (98.5%) 9 (1.5%) 607
Cyprus 1 (50.0%) 1 (50.0%) 2
Total 2798 (87.4%) 402 (12.6%) 3200
Table A-12: Hepatitis B vaccine by country
Hepatitis B vaccine
Country of employment I haven't received I have received Total
Sweden 39 (31.0%) 87 (69.0%) 126
Greece 25 (26.0%) 71 (74.0%) 96
Finland 30 (22.6%) 103 (77.4%) 133
Italy 182 (35.3%) 333 (64.7%) 515
Germany 146 (12.0%) 1066 (88.0%) 1212
Malta 1 (33.3%) 2 (66.7%) 3
Lithuania 13 (54.2%) 11 (45.8%) 24
Romania 43 (34.7%) 81 (65.3%) 124
Slovenia 9 (47.4%) 10 (52.6%) 19
Spain 104 (28.7%) 259 (71.3%) 363
Poland 16 (5.8%) 261 (94.2%) 277
UK 173 (23.3%) 570 (76.7%) 743
Cyprus 0 3 (100.0%) 3
Total 781 (21.5%) 2857 (78.5%) 3638
56
Table A-13: Td or Tdap vaccine by country
Td (adult tetanus vaccine) or Tdap (adult tetanus,
diphtheria and pertussis vaccine)
Country of employment I haven't received I have received Total
Sweden 47 (40.9%) 68 (59.1%) 115
Greece 27 (31.0%) 60 (69.0%) 87
Finland 3 (2.1%) 138 (97.9%) 141
Italy 187 (36.3%) 328 (63.7%) 515
Germany 115 (8.7%) 1209 (91.3%) 1324
Malta 1 (33.3%) 2 (66.7%) 3
Lithuania 12 (54.5%) 10 (45.5%) 22
Romania 60 (72.3%) 23 (27.7%) 83
Slovenia 15 (78.9%) 4 (21.1%) 19
Spain 90 (24.6%) 276 (75.4%) 366
Poland 139 (57.7%) 102 (42.3%) 241
UK 221 (35.4%) 403 (64.6%) 624
Cyprus 0 4 (100.0%) 4
Total 917 (25.9%) 2627 (74.1%) 3544
DG SANCO Public Health Program 2008 – 2013
IMMUNIZATION BARRIERS AND ENABLERS AMONG HEALTH
CARE PROFESSIONALS: ANALYSIS OF FINDINGS
2013
This report has been written by Dr Vasilios Raftopoulos, Assistant Professor of
Nursing in the Cyprus University of Technology based on the focus groups
conducted in each of the consortium countries. The report has been reviewed
from the research team of the participating countries.
Part B: Report on the findings of the focus group
conducted in the seven countries
REPORT OF FOCUS GROUPS RESULTS
2
Abstract
Background: Within the framework of the European project “Promoting immunizations for HCWs
in Europe” HCWs’ attitudes, organisational and attitudinal barriers and enablers towards
immunization were explored in Greece, Italy, Germany, Cyprus, Romania, Poland, and Lithuania
to guide the development of a toolkit to increase vaccination coverage in HCWs.
Aim: The aim of the current research report is to summarize views, needs, barriers (triggers both
organizational and attitudinal) and enablers of Healthcare workers towards immunization and
vaccination in the seven countries.
Sample and method: The sample consisted of 282 HCWs. The convenience sample was recruited
from hospitals and other settings from 7 countries. A focus group approach has been selected.
Results: the participants were knowledgeable about vaccinations and immunization. In general the
HCWs of the sample have emphasized the importance of immunization and were favorable to their
vaccination and that of the public. Many of them were familiar with the booster immunization
program. The vast majority of the participants considered that HCWs belong to the high risk
groups for acquiring a vaccine preventable disease. The main reasons given for not being
vaccinated were: thinking it was not needed, concern about its effectiveness, delayed availability
and distribution of influenza vaccines, lack of support regarding the provision of information on
the benefits of immunisation, physicians do not recommend vaccination to their patients, lack of
prevention strategies, lack of authorities’ commitment to vaccination, lack of accessibility to
vaccines for the vulnerable population, different immunization schedule among the EU countries,
lack of an expert in epidemiology in each hospital and the existence of an anti-vaccination
movement after the experience of H1N1 pandemic in 2009. Some of the enablers for vaccination
are the followings: the belief that the main perceived benefit of vaccination was personal and
patient protection against influenza, perception that vaccination protects them and their families,
educational programs and materials, the role of occupational physician as a key person for
promoting vaccination, the existence of a National Seasonal Campaign, self awareness of HCWs for
immunization and the role of the infection control personnel.
Conclusion: Targeted health education programmes should be developed to overcome
misconceptions about influenza vaccination.
Keywords: immunization, influenza vaccination, healthcare workers
REPORT OF FOCUS GROUPS RESULTS
3
Introduction
Despite recommendations by the World Health Organization and Centres for Disease
Control and Prevention (CDC and ECDC) that have been endorsed by many European countries,
and the documented benefits for healthcare staff, vaccination coverage levels in healthcare staff
remain unacceptably low.
Many studies have examined why healthcare staff do not receive an annual influenza
vaccination. Some of the reasons are fear of injections, fear of vaccine side effects and especially
influenza-like symptoms, busy schedules, fear of developing influenza, perceived lack of vaccine
efficacy, opposition to vaccination in general, low personal risk of illness, avoidance of
medications, lack of time and forgetting to get the vaccine.
Thus the in-depth exploration of the views, needs, barriers (triggers both organizational and
attitudinal) and enablers of Healthcare workers (HCWs) is crucial for the development of a
structured policy to increase vaccination coverage levels in healthcare staff.
Aim
The aim of the current research report is to summarize views, needs, barriers (triggers both
organizational and attitudinal) and enablers of HCWs in the seven countries.
Sample and method
The sample consisted of 282 HCWs. The convenience sample was recruited from hospitals
and other settings. Table 1 presents the composition of the sample across the seven countries.
The focus group approach was selected for data collection as it involves and uses group
interaction to generate data. Before beginning the focus group interviews a questionnaire was
administered to gather information about socio-demographics, and work experience of the
participants. For most of them, the focus group offered a unique opportunity to express their
feelings, to provide distinctive types of data and to clarify their attitudes to vaccination in a way
that would be less easily accessible in a one-to-one interview. In some cases the one-to-one
interview has been used.
Taking into consideration the need to guarantee validity and reliability in the collection of
qualitative data, the focus group discussions were analysed in a continuous way, giving feedback to
the participants for additional comments. The questions were open-ended, neutral, sensitive and
well understood by the participants. All focus group interviews were recorded and transcribed
verbatim.
Participants received an explanation of the purpose and aim of the study, and those who
agreed to participate were asked to provide verbal consent. No personal identity information was
REPORT OF FOCUS GROUPS RESULTS
4
documented and participants were informed that they had the right to withdraw from the study
whenever they wished. The focus group interviews were completed between 2012 and 2013.
Results
Italy
1. Nurses and physicians
In Italy HCWs have emphasized the importance of immunization and were generally
favorable to vaccination. However, all the participants agreed that the insufficient knowledge or
incorrect information on the benefits of vaccination could explain the lack of vaccination
awareness. Moreover, professionals with a lower educational level tended to trust the more
competent colleagues and rely on them. In general training, communication and dissemination of
information were considered essential, especially if these activities are carried out in an interactive
way. In addition, they stressed that information on vaccination should be based on reliable and
valid data as well to be individualized.
Both personal and family protection influence the decision to have the vaccine. In addition,
previous personal experience of a vaccine preventable disease, in particular if complications were
experienced, is considered to be cue to action that includes personal vaccination and vaccine
recommendation to the others.
A suggestion for increasing vaccination coverage is to take advantage of the periodical
medical examination/check up performed by the occupational physicians for promoting and
administering vaccinations and to create a computerised vaccination registry.
2. Hospital administrators and infection control personnel
The more important VPDs mentioned by the participants were Hepatitis B and influenza.
They considered themselves to be susceptible to a VPD. They believed that vaccination protects
them from a VPD. Self protection seems to be a major predictor for getting the vaccine rather that
the protection of the patients.
All the participants commented the need of promoting and increasing vaccination coverage
among HCWs by providing friendly strategies and educational materials about the vaccines.
Integrated campaigns, customized and based on twofold communication are deemed essential for
the dissemination of reliable information among the HCWs.
REPORT OF FOCUS GROUPS RESULTS
Table 1: sample composition
Target group Italy Germany Greece Cyprus Romania Poland Lithuania
FG (n) FG (n) FG (n) FG (n) FG (n) FG (n) FG (n)
Physicians 3 (28) 3 (11+3) 4 (30) 2 (12) 1 (7) 2 (18) (4)
Nurses 2 (19) 2 (8) 1 (8) - (7)
Administrative & Infection
Control Personnel
2 (21) 2 (6) 2 (11) 4 (4)* 2 (16) 2 (9) (11)
Public Health Personnel &
Policy Makers
1 (7) (**) 1 (3) 2 (2) (*) 4 (4)*
1 (8) 2 (12) 2 (13)
Total 6 (56) 6 (23) 10 (62) 12 (28) 5 (39) 6 (39) (35)
(*) Personal interviews
(**) The one FG was a face to face interview
REPORT OF FOCUS GROUPS RESULTS
6
For several participants immunization should be a pre-requisite for working in the health
sector. There is a need to develop National Guidelines or protocols that could be easily
implemented at local level, as well as to obtain the relevant budget.
The participants emphasized the role of the occupational physician as a key person for
promoting vaccination and documenting the vaccination status of the healthcare workers.
3. Public Health Personnel and Policy Makers
All the participants believed that HCWs are in general at high risk for VPDs. In particular,
for Hepatitis B, measles, mumps, rubella, flu and pertussis. In Italy, vaccination for HCWs is not
mandatory except for tuberculosis which is compulsory for those HCWs at high risk for exposure
to multidrug-resistant TB strains. Some participants did not consider compulsoriness as an efficient
way for increasing vaccination coverage in general and for HCWs in particular. The development
and implementation of national immunization campaigns is not considered for all the participants.
Availability of information and statistical data on immunization is considered to be a need. The
main enables that emerged, are education/information, the implementation of National
campaigns for the vaccination of HCWs, economic factors, legal and ethical aspects.
HCWs are often overwhelmed by scientific papers, leaflets or several forms of advertising
that they do not read or consider. Workshops, congresses or meeting are the most effective way
to exchange opinions with colleagues and to update knowledge. Moreover case-histories are
considered very informative, sometimes more than any scientific meeting or congress.
Table 2 includes the main findings of focus groups as well as the comments of the
participants.
Greece
1. Nurses
Greek nurses seem to constitute a rather heterogeneous target concerning their knowledge
and beliefs about immunization as those aged <40 years-old were rather sensitized on vaccination
and realized that they are at high risk as opposed to those >40 years-old. Hepatitis B vaccine is
considered an important vaccine that protects from acquiring the disease. Nurses >40 years-old
were not familiar with the booster immunization program. On the contrary those age <40 years old
carried detailed knowledge due to personal sensitization. All participants reported that adult
immunization protects from dangerous diseases and acknowledged the importance of early
vaccination.
In Greece seasonal influenza vaccine is well known to them due to the annual National
Campaign. Yet, participants reported a low level of compliance with influenza vaccination.
Moreover, the existence of a National Campaign only for seasonal Influenza and not for other
REPORT OF FOCUS GROUPS RESULTS
7
vaccine that are long-lasting and are also connected with dangerous diseases generate suspicions
and cultivates feelings of insecurity that are related to the relationship between nurses and the
market system.
Nurses reflected that HCWs immunization is an evidence of the willingness of the health
care system to protect its employees from vaccine preventable diseases. They emphasized the
absence of a formal well-organized plan for assuring HCWs immunization that should have been
administered to all the hospitals of the country and could include both seasonal and long lasting
vaccinations. Infection Control personnel in each hospital is perceived as the focal point and the
main person that is accountable for performing HCWs vaccination.
Nurses have identified several organizational barriers to vaccination such as: (1) lack of a
structured and informal national plan for assuring HCWs immunization in all the hospitals, (2) lack
of information and knowledge on adult/booster immunizations, (3) difficulties faced by the HCWs
concerning the supply of adult/booster vaccines: relating to the prescription of vaccines in the
hospitals, economic barriers due to the need of purchasing the vaccine. The attitudinal barriers
concerning HCWs’ immunizations were the following: (1) lack of sensitization on preventive
initiatives, such as immunizations (2) lack of knowledge of the potential of the transmition of the
disease to the patients, (3) overall belief that HCWs are well “armored” against diseases, (4)
underestimation of personal hygiene measures in order to protect their selves and patients, (5)
work pressure and overload, (6) self-protection and protection of patients are not directly
connected with the relative disease, (7) doubts about the effectiveness of the vaccine (new and not
well-tested), (8) lack of knowledge and information about its side-effects, (9) Scapegoat” for the
absence of information and knowledge provided to HCWs about adult/booster vaccines that are
related to HCWs’ high risk exposure to infectious diseases, such as Hepatitis B.
On the other hand the attitudinal enablers concerning HCWs’ immunizations were the
following: self sensitization of HCWs on immunizations, HCWs’ higher sensitization on Hepatitis
B vaccine, perception that the uptake of seasonal Influenza vaccine that enhances HCWs’
immunizations is related to the protection of their family-children or/and elder people. The
organizational enablers concerning HCWs’ immunizations were the following: Dynamic action of
infection control personnel on HCWs’ immunization (Keeps personal immunization records of
hospitals’ employees, informs HCWs’ about all kind of immunization -seasonal, booster, pandemic-
through door-to-door visits in each clinic of the hospital, reminds HCWs the time for
immunizations repetition), door-to-door practice (overcomes the barrier of HCWs’ work pressure
& overload) and direct communication that promotes a sense of “caring” for the employees.
REPORT OF FOCUS GROUPS RESULTS
8
2. Physician
Immunization is a widely accepted practice for Greek physicians that is enhanced through
their studies. The importance of Hepatitis B vaccine is highly recognized by the physicians, since it
is connected with a very risky infectious disease that could affect them. Moreover, Hepatitis B is
the most common occupational risk mainly after a needle stick injury. Physicians commented that
both Hepatitis B vaccine and the testing of the HBV antibodies should be provided to all the
physicians from the beginning of their studies. Physicians indicated their rather controversial
stance towards seasonal Influenza vaccine and relatively low level of compliance despite the fact
that it is the only vaccine provided to them annually for free, through the National Campaign.
The lack of information and knowledge concerning booster immunizations is a barrier for
getting the vaccine with the exception of pediatricians who have an extended knowledge on the
issue due to their specialization.
Regarding the ways through which physicians are getting informed of the immunization the
participants have mentioned that they personally conduct a literature review on specific vaccines.
They considered Hellenic Centre for Diseases Control and Prevention as the efficient and official
agency regarding the provision of information for HCWs’ immunizations.
According to the Greek physicians the main barriers of HCWs immunization are categorized
in: (1) Organizational: Lack of a consistent organizational infrastructure and clinical practice
concerning HCWs’ immunizations in all the hospitals of the country to establish specific
regulations, lack of knowledge and information provided to physicians about adult/booster
vaccinations. As a result physicians neglect the issue of information and knowledge concerning
immunizations. Belief that immunization is the responsibility of paediatricians and epidemiologists.
(2) Attitudinal: HCWs’ immunization is not a personal issue but an issue that the health care
system should take care of. Additionally, work pressure & overload, the belief that seasonal
influenza is not perceived as a high risk infectious disease compared to other diseases, such as
Hepatitis B, uncertainty about the effectiveness of the vaccine.
3. Administration & Infection Control personnel
The infrastructures that are accountable for HCWs’ immunizations are the Infection Control
Office in each hospital and the Occupational Health Office, although in Greece Occupational
Health offices do not exist in all the hospitals. The excess sensitization of the Administration and
Infection Control personnel on the importance of Hepatitis B vaccination for the HCWs is linked
with the high risk of occupational exposure to that infectious agent. As a result the protection of
HCWs against Hepatitis B by getting the vaccine is considered rather essential.
REPORT OF FOCUS GROUPS RESULTS
9
The awareness of the Administration and Infection control personnel towards Seasonal &
Epidemic Influenza is attributed to the experience obtained from the H1N1 epidemic, although
there are major concerns about the safety of the vaccine due to the side effects. The Administration
and Infection Control personnel considered there is a lack of adequate information and knowledge
concerning booster immunizations.
The organizational barriers of HCWs’ immunizations were the followings: lack of National
Campaigns/official initiatives concerning HCWs’ immunizations – existence only of the epidemic
and seasonal Influenza’s National Campaigns, lack of knowledge and information provided to
Infection Control personnel by official bodies about HCWs’ vaccinations, lack of Infection Control
personnel’s initiatives or spontaneous initiatives on HCWs’ immunization, lack of available
vaccines, difficulties faced by HCWs concerning the delivery of vaccines (not prescribed in the
hospital and financial difficulties, since the cost of the vaccines is not coved by the hospital and not
always covered by HCWs’ insurance)
The attitudinal barriers of HCWs’ immunizations were the followings: HCWs’ work pressure
and overload, overall sense that HCWs are well “armored” against diseases, HCWs’ lack of
sensitization on the fact that immunizations are not only connected to the self-protection but also
to the protection of patients and the whole society; lack of specific knowledge and information
concerning adult/booster immunizations, HCWs’ belief that seasonal influenza is a low-risk
disease, self-protection and protection of patients against seasonal Influenza is not directly
connected with the relative vaccine, seasonal Influenza vaccine’s main competitor is the mask and
the specific knowledge that HCWs carry due to their occupation concerning safety measures
against risks connected with the transition of diseases, lack of knowledge, information and
sensitization on their responsibility for patients’ protection against seasonal Influenza.
The main organizational enablers of HCWs’ immunizations were: Door-to-door practice
(enhance HCWs’ sense that the “system is taking care of them”), HCWs’ work pressure & overload,
HCWs’ knowledge & information gap concerning immunizations. The main attitudinal enablers of
HCWs’ immunizations were: the sensitization of HCWs on Hepatitis B vaccine. Regarding seasonal
Influenza vaccine protection of HCWs’ family members, such as children and older people is a
rather strong trigger
4. Policy Makers & Public Health Personnel
Policy Makers & Public Health Personnel argued on the importance of booster
immunizations in general. They have also paid greater attention of seasonal Influenza vaccine in
comparison to booster immunizations. Consequently, great emphasis has been given to the
promotion of HCWs’ seasonal Influenza vaccinations and there is launch of a relative National
REPORT OF FOCUS GROUPS RESULTS
10
Campaign annually. According to them HCWs who work in hospitals are at higher risk for
acquiring a VPD than private physicians.
According to the policy makers & public health personnel the main Organizational barriers
are the followings: lack of a formal framework -Law- concerning HCWs’ immunizations, lack of
knowledge and information provided to each hospital by official bodies about HCWs’
immunizations with the exception of seasonal Influenza vaccine due to National Campaign,
difficulties faced by HCWs concerning the delivery of vaccines in the each hospital.
The attitudinal barriers are: the overall sense that HCWs are well “armored” against diseases,
lack of sensitization on the fact that immunizations are not only connected to self-protection but
also to the protection of patients and whole society, Greek doctors’ and nurses’ lack of a prevention
culture, anti-vaccination movement, which is followed by rejection of immunizations in general,
HCWs consideration that seasonal influenza is a low risk disease as far as their self-protection is
concerned compared to Hepatitis B, misconceptions related to the safety of the seasonal Influenza
vaccine that generate fear of the seasonal Influenza vaccine and the role of the physicians as
opinion leaders in order to restore the truth concerning the safety of the specific vaccine.
The enablers of HCWs’ immunization were bipolar: attitudinal (personal sensitization of
HCWs) and organizational (sensitization, initiatives and dynamic action of Infection Control
personnel in each hospital).
Cyprus
Generally HCWs were very positive regarding vaccination and they strongly agreed with the
vaccinations, since according to them vaccines protect HCWs. Vaccines provide high degree of
protection not only to HCWs and the patients but also to the general population.
All HCWs at Health Care premises must be vaccinated since they are at high risk to get sick
and also they should be convinced that with vaccines they will not ‘get’ the disease and moreover
they not ‘give’ the disease. HCWs are at higher risk for the listed vaccine preventable diseases than
the general population. HCWs who work at the ‘front line’ are at high risk as the other HCWs who
have close conduct with large number of patients. The most dangerous vaccine preventable
diseases from the list provided are Hepatitis A and B, Tuberculosis and Pneumococcal disease. The
HCWs are at greater risk for the Influenza, Tuberculosis, the Meningitis, and the Varicella disease.
The majority of HCWs claimed that they are not sure whether the vaccine for the seasonal
influenza is useful. Despite that the seasonal influenza vaccine is generally done by the majority of
HCWs. They have many doubts about the influenza vaccine. Moreover, many HCWs do not
consider that Influenza is a serious disease. Thus they have reported that Seasonal influenza
vaccine is not important at all. That group of HCWs was actually very negative to the Seasonal
REPORT OF FOCUS GROUPS RESULTS
11
Influenza vaccine to the HCWs. On the contrary that group of HCWs was very positive about the
Hepatitis and Tetanus vaccine.
HCWs are also at risk especially when patients do not report that they have a transmitted
disease. Usually HCWs use the safety regulations and thus they are to some extent protected.
Sometimes patients do not know if they have a transmitted disease. On the one hand vaccines
protect the HCWs but on the other hand HCWs have to protect themselves such as preventing
accidents with used needles.
HCWs should be free to decide whether to make the vaccines or not and afterward to be
fully responsible if they get any transmitted disease. HCWs should be vaccinated but it should be
up to the individual to decide whether to make the vaccines or not. Information would be the
stronger instrument despite the fact that it is not always that the case and HCWs end to have
misinformation. Information is very important topic. Misinformation is vital issue at Cyprus.
Prevention is the best treatment. HCWs lack awareness and many HCWs have ignorance about the
benefits of the vaccinations may be because they have not pay any special attention to the utility of
the vaccines and have not been correctly informed. HCWs need to be more informed about
vaccines. Lately some HCWs have changed their positive opinion about vaccines. They become
more negative about vaccines as time pass. In reality some HCWs are not convinced ‘what’ a
vaccine does. Some of them have commented “vaccines are ‘inserted’ into our bodies without
knowing if our bodies’ immune system is ‘ready’ to ‘accept’ or to ‘receive’ the vaccine”.
From all the media a huge awareness campaign was organized which had great positive
impact on the general population. At that time also very negative comments were published about
the negative side effects of the vaccine claiming that such a new vaccine should not be used. People
were confused. At hospitals not all vaccines are for free. Some of the vaccines are very expensive.
That can be a strong barrier. Some of the vaccines are not available at the governmental hospitals.
The strongest barrier for vaccinations is most often the vaccines’ cost and people’s ignorance and
neglectfulness. Some HCWs do not agree that the cost is the strongest barrier. In the past the
strongest barrier was ignorance. Information and awareness campaigns should start from the school
age.
At the governmental sector in each hospital there is an Infection Department with only one
nurse as a staff. That nurse should take care of all the HCWs and the general population as well.
That is practically impossible thus it was strongly suggested to support and upgrade the Infections
Departments. Media should not announce medical news after adjusting them in such way to be
‘attractive’ or ‘interested’. The media’s approach is unacceptable and it occurs almost on daily base.
Law should be developed as soon as possible. A medical scientist or expert in the area should be the
one either to present the ‘case’ or at least to ‘approve’ what will be announced. A national program
REPORT OF FOCUS GROUPS RESULTS
12
is needed for the HCWs vaccines. Guidelines are needed and national plan is a necessity and thus
should be developed as soon as possible. HCWs need urgently a National plan. The Health care
Policy maker should ‘place’ HCWs at the right ‘track’. The current situation will change with the
development of a national strategy. Seminars about vaccines should be done to remind HCWs and
to sensitize them to start making check-ups.
Lack of time was mentioned as the strongest barrier, HCWs believe that they do not need
the vaccines. Many of them do not get the vaccines because of ignorance of the benefits. A national
program and regulation should be developed for compulsory vaccination of the HCWs. A strategy
should be developed for the HCWs to oblige them to do the compulsory vaccines. No more
seminars are needed for the HCWs since they know everything about vaccines. They only need a
law to force them to get the vaccines otherwise they will not get them. Laws would be very
effectual.
Lithuania
1. Nurses and physicians
All HCWs recommend vaccination for the children. Especially paediatricians promote
immunization of children. Paediatricians and nurses get an incentive for every immunized child
from the National Insurance Fund. The participants of the focus groups have mentioned the
following vaccines for adults: vaccine against Hepatitis B is necessary to prevent transmission
through blood; the TB vaccine is not available to the adults, vaccine against HPV is provided only
for young people. Revaccination against diphtheria should be done once every 10 years;
vaccination against encephalitis is quite important for certain population groups; re-vaccination
against tetanus should be done; vaccination against flu is available but many people are in doubt
about it. Vaccination coverage of general population against tetanus and diphtheria is low and the
same pattern applies to HCWs as well. The vaccines against encephalitis and Papiloma virus are
quite expensive.
All HCWs are undoubtedly exposed to infectious diseases compared to the general
population. HCWs could be classified into several groups according to their daily practice and
exposure to several risk factors. One group could be professionals who have a direct contact with
blood during their routine daily working tasks (obstetrician-gynaecologists, surgeons etc). Most
frequently they are exposed to Hepatitis B. The second group includes the other workers in the
health care sector, who are exposed to viral and other infectious diseases via the respiratory system
(flu), such as health administrators, nurses, family physicians, laboratory workers etc.
In general, HCWs still believe that the only effective preventive measure against infectious
diseases is vaccination. The negative attitude towards vaccination is a personal norm and there is
REPORT OF FOCUS GROUPS RESULTS
13
no space for discussion. A lot of negative information about vaccination is provided in the mass-
media. There is a need to inform and convince journalists about the benefits of vaccination given
that they disseminate a lot of negative information about vaccinations and physicians. A general
comment of the participants was that during the pandemic several years ago, a very bad practice
with too late vaccination has significantly ruined the reputation and reliability of immunization in
general. This event has significantly ruined the reputation and reliability of immunization in
general.
One of the barriers for immunization both for HCWs and the general public is the financial
burden due to vaccine costs in case they are not provided for free. Municipalities lack competency
to work with immunization issues in general public.
Everybody agrees that information campaigns are important. However the participants recall
in their mind information campaigns provided by representatives of pharmaceutical companies. A
separate programme could be developed regarding re-vaccinations from whooping cough, tetanus,
diphtheria. A separate financial inducement for professionals for provision of immunization
services could be introduced as it is in the case with children immunizations.
2. Administrative and infection Control personnel
Working in the healthcare sector is considered risky as regards the risk to get contagious
diseases at work. At the highest risk remain professionals who have a direct contact with blood.
Additionally they are exposed to viral infections and other wide variety of infections transmitted
by patients. The most serious infectious diseases are: Hep B, Hep C, HIV, other bloodborn
infections, influenza as well as infections from pathogens that are resistant to antibiotics
The general population lacks medical information on immunization against infectious
diseases. There are HCWs, who are not interested in medical updates as well and are behind
contemporary knowledge and do not recommend vaccinations to their patients and do not get
vaccinated themselves. There is also a reduced access to vaccines in Vilnius attributed to the fact
that there was an immunization unit at Lithuanian Communicable Diseases and AIDS centre in
Vilnius that has been closed. As a result the general population should visit the GPs to get the
vaccines. This creates additional workload for the GPs who are overloaded with their daily
activities.
The absence of immunization campaigns either on a national or on a regional level has been
reported from all the participants. In general more reliable information on the benefits of
immunization should be produced and distributed by the public health centres. There is a
mandatory reporting system for vaccinations and side effects. The facilities are reporting in unified
way a number of vaccinations (children and adults groups, diseases and types of vaccines) on a
REPORT OF FOCUS GROUPS RESULTS
14
monthly basis to territorial public health centre. The information related to the number of
immunized staff is reported to regional public health centre and they forwarded the information to
National communicable diseases and AIDS control and prevention centre.
Poland
1. Nurses and physicians
There was a negative attitude towards vaccination. The main reason is that although two
years ago the sanitary-epidemiological agency has informed that vaccination would be for free, in
fact, the vaccines have never come in December, even in January. It came at the end of February,
and almost everyone who earlier has requested the vaccination, resigned. A proportion of the
participants got the vaccine on their own. Furthermore the participants have commented the lack
of immunity tests after the vaccination.
The benefits of vaccination are the reduced number of sick leaves, and the fact that vaccines
are cheaper than later compensation.
There was a gap in the percentages of the vaccinated healthcare professional as 95% of the
nurses are vaccinated, as opposed to 50% of the physicians.
The main barriers-triggers for vaccination are the following: People are getting sick after
vaccination, financial issues (if employer refund total price of vaccine almost 98% people would be
vaccinated), the provision of information from the Media without the supervision of a physician,
carelessness among physicians, lack of awareness concerning vaccination, keeping vaccine in bad
conditions (problem with storage of these vaccines), fear of vaccines, wrong Act concerning MP,
cooperation between MP physicians and employers, too many duties and heavy workload among
physicians, lack of the knowledge of the law (there were changes in regulations concerning
documentation regulations have changed recently), lack of training among physicians, lack of
education, preventive actions after working hours is not welcomed from the employees, lack of
information concerning healthy life, hard to find information where vaccination takes place.
The main enablers are the perception of the right path for getting the vaccine and trainings
for nurses and physicians.
2. Policy Makers & Public Health Personnel
The policy makers and the public health personal have expressed some speculations
regarding the storage and the conditions of vaccines’ distribution. There is a lack of “health”
culture and lack of information concerning vaccination among employers. The distribution of the
vaccine and vaccination from the physician in the same place is preferred. The common practice is
the division of finance and division of responsibility for vaccination. Social-economic studies as
REPORT OF FOCUS GROUPS RESULTS
15
well as studies exploring the factors that correlate with vaccine uptake are useful in order to focus
of them and develop a strategic framework for vaccination. The paradigms of the policies in the
neighboring countries combined with the comments of the experts in that field are also important.
The benefit from vaccination is the decreased absenteeism.
3. Administration & Infection Control personnel
There are some vaccines, which most people consider to be necessary (i.e. vaccine against
tetanus and hepatitis). Vaccination as a common practice cannot be generalized due to the
individuality of the needs of each person. Flu and the flu vaccine are controversial due to the lack
of specialized education.
There is a differentiation in the needs of people. Besides physicians from several specialties
have a different view of the vaccination issue. Thus it is crucial to empower the experienced
physicians to transfer their expertise to the others.
The benefit from vaccination is the decreased absenteeism.
The main barriers – triggers are the following: hard to persuade people to get the flu vaccine,
lack of education, the role of Media as an opinion-forming means, lack of awareness regarding
vaccination, the dependence of Medical market on financial resources, financial barriers, lack of
physicians’ accountability relating to vaccination, lack of prevention strategies and lack of
authorities commitment.
The main enablers are: the construction of an internet portal in which everyone could log on
and fill in questionnaires, the protection of anonymity, the conduction of surveys in separate
groups and the vaccine uptake in the workplace.
Romania
1. Nurses and physicians
Nurses have been the most enthusiastic; they know the procedures, better than the
physicians; they perceive the importance of immunizing the population and especially the HCWs.
The physicians are responsible for vaccination. The nurses and the physicians highlighted the
followings: transparency, communication of the national strategy regarding immunization and
coverage of migrant population or particular population groups at risk are poor, especially those
who live in isolated geographical areas. The budget for the vaccines, the information about
pharmacy vigilance and the vaccination schemes are low. The use of communication tools to
enhance the benefits of immunization is sparse. The physicians have a positive attitude regarding
vaccination. There is inconsistency/ambiguity regarding the National Immunization Program (not
very clear, coherent ideas about what type of vaccines should be in the National Immunization
REPORT OF FOCUS GROUPS RESULTS
16
Program). There are different immunization schemes among EU – the national calendar is not
updated in real time, some of the so called important vaccinations are not yet in the National
Immunization Program (i.e Anti pneumococcal, rotavirus and HPV vaccination).
There is limited age coverage (only children 0-1 year old age), population at risk are not
covered in the National Immunization Program (i.e older age for influenza, different type of
professionals including HCWs, some other specific vaccines, etc.). The budget is under financing
constraints. There are also some difficulties in reporting on immunization (both to SIUI and to the
RENV); difficulties in validating performed immunizations (especially for the children 0-6 month)/
lack of compatibility of software used in PHC with SIUI/ software of the RENV.
There is a need to: take informed and evidence based decisions, including local context
information and data relating to updating national vaccination schedule, assure access to scientific
international databases, to reengineer the system that collects data regarding immunization
(National Electronic Register for Child Immunization), increase the number of studies published in
the local context / health services research, to assure the adequate budget for National
Immunization Program and to create an eligible institution empowered to communicate about
prevention and vaccination benefits.
Some of the barriers – triggers are: the lack of communication regarding the vaccination
benefits to the general public, the under finance of the National Immunization Program, the lack
of communication regarding the vaccination benefits to the general public, the lack of information,
training, the lack of knowledge or adequate information about disease exposure, the lack of time,
lack of money, lack of commitment of personnel compulsory HCWs’ vaccinations and lack of a
expert in epidemiology in each institution. Attitudinal related barriers are fear of side effects,
beliefs that they are not at risk of getting flu.
2. Public Health Personnel and Policy Makers
Public Health Personnel and Policy Makers shared similar views regarding immunization,
with nurses and physicians.
Germany
1. Nurses and physicians
For the HCWs vaccination is of high importance as it protects not only themselves but also
their families. They perceived a lack of knowledge and disinterest among the population (many
parents decide that their children should not get vaccinated). Vaccinations are rational for certain
groups (elderly patients, patients with diabetes and other immunodeficiency diseases). A lot of
people are hostile to vaccinations. In many cases there is a skepticism regarding vaccinations
REPORT OF FOCUS GROUPS RESULTS
17
against influenza and a lack of risk awareness. The attitude of HCWs does not differ from that of
the general population. The implementation of mandatory immunizations is controversially
discussed. There is also a societal consensus regarding immunizations. The use of reminder for
vaccinations is welcomed from the HCWs. The Media do not promote vaccination in an effective
way. Physicians have to be confident of vaccinations.
The benefit of vaccination is the protection against the diseases and as a result the
improvement of populations’ health.
The barriers-triggers of vaccination are the following: pseudo-knowledge / lack of
knowledge, lack of risk awareness, the attitudes of paediatricians and general practitioners towards
vaccination, the way vaccination is presented in the mass media, fear of injections/needles,
financial barriers and lack of time, doubt about the efficacy of the vaccination.
The enablers of vaccination are the attitude of general practitioners and pediatricians and
the role of mass media.
2. Policy Makers & Public Health Personnel
Vaccination is considered to be important for policy makers and public health personnel.
They stressed that there is lack of knowledge/disinterest regarding vaccinations of HCWs.
Physicians and general practitioners need more education regarding vaccination. The vaccination
should be mandatory. The extent use of reminders/checks and vaccination card is important.
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Table 2: HCWs focus groups
Professionals Topic Country Example of transcribed verbatim
Nurses and
physicians
1. Views Italy The more common vaccines
- for HCWs: Hepatitis B, influenza, pandemic H1N1virus,
tuberculosis, varicella
- for patients and general population (especially pediatric
population): hepatitis b, exanthematic diseases, influenza,
pandemic H1N1virus, HPV, tuberculosis, rubella, measles,
mumps, Meningococcal, Pneumococcal, varicella
Lack of information for the benefits of vaccination "I believe that there is not a substantial difference on this field between general population and HCWs. It is a so complex matter that my colleague medical doctor, has not a different perception than the person working on the street" “Few information on vaccinations issue" "There is a big problem on information" "Above all, there is ignorance" "If the HCW is not a specialist, he is not more educated than ordinary people"
Hospital
administrators and
infection control
personnel
They perceive their vulnerability to VPDs "It 's well known that the risk of contracting hepatitis for people working no-stop in the operating room is very high and continuous, but how many HCWs are vaccinated?" "In a situation where health workers are working in emergency room, visiting 40 people every day, maybe in a crowded room, they should be immunized against influenza”.
Generally, vaccination, especially that for hepatitis B, is
considered by participants an effective way for their own
"Vaccination against measles is not only to protect the patient, but also to protect the health worker”
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protection and for patient’s protection
Although seasonal influenza is generally seen as a mild
problem, the 2009 pandemic was perceived as potentially
dangerous
"The event of the H1N1 pandemic has obliged the health care workers, for the first time, to consider a new vaccination. From an epidemiological point of view the risk was irrelevant "
Public Health
Personnel and
Policy Makers
In general, according to the policy makers, in Italy national
health communication activities or campaigns have been
implemented for the general population, while for HCWs such
activities have been conducted only at a local level
““There is none of those campaigns” “I don’t remember any national education campaign targeted to HCWs except for the last influenza pandemic” “Some region implemented few programs”
Nurses and
physicians
2. Needs and
benefits Italy The need of specific information about the different vaccines, as
well as the importance of vaccination in the prevention and
health protection
“I work in an emergency room but I don’t wear gloves or mask all the time because it is difficult to work wearing them, therefore I prefer to vaccinate myself because I can be a possible source of infection, rather than vaccinate my children” “This year I think I’ll get vaccinated against flu because I can’t afford a long sick leave neither from a family nor from a working point of view”
Need of reliable data on VPDs incidence, vaccination coverage,
incidence of sequelae, of gaining knowledge e.g. through
specific seminars and toolkits, of appropriate premises for
administering vaccination in hospitals
The main benefits include protection of both HCWs and
patients
“We are on the battlefield, in direct contact with patients, sometimes we work in critical situations with immune-suppressed patients and perhaps we should pay more attention” “It may happen to assist a not very severe patient but he can get worse because we are vehicle of viral infection” “I think HCWs should be vaccinated in general and for flu in particular, not for their safety but for patients’ safety, especially those with chronic diseases. Often people come into the hospital for a reason and die due to our fault”
Hospital Italy Participants considered vaccinations a good way of protecting “Vaccinations are a good way of protecting patients”
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administrators and
infection control
personnel
HCWs and patients "The health worker must also be vaccinated to prevent transmitting diseases to patients within the health care setting"
Public Health
Personnel and
Policy Makers
Appropriate communication strategies and education activities
Availability of information
Availability of statistical data
Shared strategies for promoting HCWs vaccination at national
level, for disseminating scientific evidences and for logistic
should be developed and supported by a financial investment
“It should not be a kind of quick promotion via slogans, targeted to the general population. The communication should be tailored to suit the HCWs; the advice should be a summary of the scientific evidences. It should be a three-page document annexed to national vaccination plan explaining in short, specific issues (i.e. thimerosal, etc.). It should have the same strength, credibility, ability to persuade, of the original documents but it should be clear and concise” “We should find a way to tailor the information to the target. My question is: why should I be vaccinated? I need to be convinced of the benefit-risk ratio “
Nurses and
physicians
3. Barriers -
triggers
Italy Risk perception influences the attitudes towards vaccination in
several ways. Several times HCWs do not feel at risk of
contracting diseases.
The risk perception seems to be lower with vaccines defined as
"historical" (such as DTP vaccine) rather than with the
influenza vaccine, considered the most dangerous and less
effective.
The safety of the vaccine appears to be fundamental in the
choice of vaccination.
Generally, the risk perception influences the attitudes towards
vaccination in different ways. It has been pointed out several
times that the HCW does not feel at risk of contracting diseases.
The lack of trust, sometimes the absolute mistrust, and low
credibility in government institutions and in controllers were
"I was practically forced to get the vaccine to enter to the university. Then after studying and reading in literature, we discovered that the vaccine could cause multiple sclerosis, it could be a trigger for the disease.." “People strongly perceive the economic interest and business behind pharmaceutical companies and this creates a strong distrust” "I believe that all HCWs consult the internet encyclopaedia searching description of vaccines, contraindications, composition and information looking for a confirmation of the news published in the newspapers "in my opinion, overestimating or underestimating
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important variables in the decision to get or not vaccination.
Participants also complained about the lack of transparency of
the drug control agencies.
One of the most problematic aspects mentioned was the lack of
information and knowledge about vaccines. The participants
argued that HCWs often do not have adequate information and
emphasized that there is no complete information on vaccines,
for example in terms of positive effects and possible adverse
effects. Some argued that the lack of knowledge and
understanding may result in an attitude of mistrust and lack of
confidence in vaccination. In contrast, others argued that a
greater knowledge may adversely affect the behaviour.
vaccines a priori is incorrect. On the contrary, it is good to obtain high-quality information and statistic data" "It is more productive to actively promote vaccinations, provide scientific information and not just opinions"
Hospital
administrators and
infection control
personnel
Some participants emphasized that HCWs have a low disease
risk perception. Moreover, participants highlighted that people
and HCWs in particular, do not seek advice concerning
vaccination or just few of them.
Trust in the Institutions, both National and International, seem
to be very low. Diffidence against pharmaceutical industry is
often reported
Lack of or incorrect information is considered the most
frequent cause of low compliance to vaccination among health
care workers.
“The risk perception is low” "Indeed, their risk perception [...] is almost nonexistent." “Yes, it is low regarding themselves. People ask more in favour of a relative, but not on themselves” “I’m a doctor,… I don’t get sick …. I don’t seek advice.. I don’t want to risk an anaphylactic shock… “Health care workers lack information about the vaccine preventable diseases against which they should be immunized” “…in my opinion HCWs are not motivated to find information for better understanding…” “Fear must be tackled trying to explain the reasons behind the fear..” “Information should be substantiated and updated, because all of us have heard about vaccine and autism, but not all of us know that this link has not been demonstrated”. “I agree that more than the ignorance the real
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obstacle to HCWs immunization is a presumed knowledge”
Public Health
Personnel and
Policy Makers
Lack of communication; participants think that people is often
confused by inconsistent or missing information published and
disseminated
Too complex messages are considered an obstacle for a correct
information about vaccination
Lack of educational activities and information
Lack of national guidance
“I think, on a hand, no one reads that documentation. On the other hand, the institutions do not know how to promote vaccination. The new National Vaccination Plan was approved in March 2012 but it was not properly disseminated: no press conferences or press releases were prepared” “Pandemic has been a crucial event: communication problems and incorrect information played a relevant role in the failure of the vaccination campaign”
Nurses and
physicians
4. Enablers Italy
Self-protection and the protection of patients were identified
not only as needs but also as motivational factors in support of
vaccination
The trust is also seen as an enabler, in particular the confidence
in senior colleagues. So the trust is given to people inside the
interpersonal relationships. Generally a psychological
subjection to the cultural hierarchy by two different career
levels (trainee towards medical practitioner, junior towards
senior) was perceived.
"Unfortunately, the risk of contracting hepatitis B is real. There is a real risk of transmitting it to patients" "I trust him as a doctor" "I would ask to a colleague whom I trust" "I ask the infectious diseases expert because I trust him" "During my pregnancy I asked to the gynaecologist colleague what was the best thing to do about vaccination for H1N1"
Hospital
administrators and
infection control
personnel
At a motivational level, self protection seems to be the most
important stimulus for vaccination uptake.
A previous negative experience could influence current attitude
and behaviour
Communication and information are unique means for the
promotion of vaccination
Implementation of training activities, based on an accurate staff
need assessment is one of the most efficacious interventions
that Institutions can use. Active versus passive approach and the
“The same influenza virus can cause a very mild disease to someone or a very severe disease to others” “….An information campaign which highlights vaccine complications…. I was not vaccinated against A/H1N1 v, because I was not in time, but, considering how bad I felt, if I could have another chance I would get vaccination.
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availability of free access informational and educational sessions
are recommended by some participants.
Public Health
Personnel and
Policy Makers
Education/information
National campaigns for the vaccination of HCWs should be
implemented
Economic factors
Legal aspects
Ethical aspects
"A doctor essentially acknowledges the scientific congresses as learning opportunities." “Case-histories are more convincing than any scientific meeting or congress. This is an important element to keep in mind, not only for highlighting the tragedies but also the hardship that vaccination involves” "Vaccination of HCWs has always been considered a marginal activity and financial investments have never been made. I think that priority should be given to financial aspects and vaccination coverage of hospitals’ employees should be included among evaluation indicators of management. Some regions have already done it." “we have to push on the ethical aspect, to encourage HCWs to get vaccination“ “The ethical aspect is the winning one” “Vaccination is not only a benefit for individual but also for the community” “The HCW should be an example for the general population”
Nurses 1. Views Greece Nurses seem to constitute a rather heterogeneous target
concerning their knowledge and beliefs about immunizations
o Nurses <40 years-old are rather sensitized on the issue and
realize the high risk of their occupation
o On the contrary nurses >40 years-old are less aware on the
issue
Hepatitis B vaccine is considered a rather important vaccine
concerning self-occupational protection
“It’s a vaccine that every year is new … every year they include new strains” “I’m afraid of all these new vaccines… On one hand
they are beneficial on the other hand I feel that I
become a “lab rat/test animal”… I’m referring also
to H1N1 vaccine.. I know that the established
vaccines… the child vaccines when they started…
they started little by little… nobody was absolutely
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Booster immunizations are not known to older nurses. The
situation is totally different for younger than 40 years old
nurses who carry detailed knowledge due to personal
sensitization. Yet, all participants connected adult
immunization with dangerous diseases and realized their
importance
Seasonal Influenza vaccine is well known to them due to the
annual National Campaign. Yet, participants indicated low level
of compliance
Moreover, the existence of National Campaign only for
seasonal Influenza and not for other vaccine that are long-
lasting and also connected to much more dangerous diseases
generate suspicions and cultivates feelings of insecurity that are
related to the relationship between nurses and the system
Nurses realize HCWs immunizations as a way through which
the health care system shows intensive care for its employees
They indicate the absence of an official well-organized plan on
HCWs immunization that would be administered to all the
hospitals of the country and would include both seasonal and
long lasting vaccinations
Infection Control personnel in each hospital is perceived as the
main responsible body for HCWs immunizations
sure and they were not accepted by everybody…
Their establishment took time… A vaccine in order
to become safe for people needs to be tested…. Not
to animals but to people. That’s how science moves
towards… To test something on people is
unethical…”
“It is very dangerous for us if we get pinched by a
needle… and we don’t any other way of protection
except of the specific vaccine”
“The most common occupational accident is to get pinched by a needle… that’s the case where HCWs feel quite insecure… and in danger”
Physicians Greece Physicians expressed a rather solid opinion concerning
immunizations in general, which addresses to their benefits and
value.
“There are no doubts that immunizations constitute a very important issue… Do not forget that due to immunizations there are diseases that have been disappeared in the westernized world…” “We as physicians have never seen some diseases due to wide spread of immunizations…” “Physicians who believe that immunizations are not effective… or have serious side-effects are ignorant… they don’t have scientific evidence for
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the particular argument and they are not good professionals.
Concerning HCWs’ immunizations physicians argued on their
great importance due to their occupational high risk exposure
“HCWs’ immunizations are not like child immunizations… they are connected with the high risk exposure of HCWs. We… as physicians… we belong to high risk population… our occupation is connected with great risks… and also we could transfer both into our patients and to the public…”
Physicians believe that Hepatitis B vaccine is the most essential
vaccines due to HCWs’ high risk exposure high self-
occupational risk
“In the emergency Unit you feel exposed to many risks… Many accidents could occur because of the panic… for instance you could get pinched by a needle…” “To get pinched by a needle is the most common occupational accident of physicians… and the disease is very serious… It affects the rest of your life” “I feel vulnerable against Hepatitis B… what if I get pinched by a needle… we are unprotected…” “In the emergency room you feel quit exposed to many risks… you could get pinched by a needle… or cut your skin… that’s very dangerous in order to get Hepatitis B…”
Greece There were wide references on seasonal Influenza vaccines,
since it is the only vaccine that is offered annually to HCWs,
who work in public hospitals.
“Every year seasonal Influenza vaccines are provided for free to us….” “Infection Control personnel pass by each Unit and vaccinate us”
The majority of physicians indicated lack of information and
knowledge on the booster vaccines within the frame of the
hospital that they are working Exception of paediatricians
Despite the specific knowledge gap physicians indicated their
wide acceptance of booster immunizations
“We are not informed about booster immunizations…” “Nobody has ever informed us about immunizations… except of seasonal Influenza… because of the National Campaign”
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“We accept booster immunizations… they are referring to vaccines that are long-lasting and tested throughout the years… Moreover, they protect against very dangerous diseases… Yet, we do not have further information about them….”
Hospital
administrators and
infection control
personnel
1. Views Period of H1N1 epidemic seems to be an essential point of
reference concerning Immunizations of HCWs that has
generated negative stances of HCWs towards pandemic and
seasonal Influenza immunizations
o Not a safe vaccine fear of side effects
o Large media coverage during the period of H1N1 pandemic
launch of the specific vaccines is connected with “conflict
of interest”
“During that period there was a mess… concerning the particular vaccines… there were informative sessions in the Hospitals’ amphitheatre about epidemic and its related vaccine… there were so many different opinions… and rumours… And media played a rather negative role… HCWs were rather suspicious on the particular vaccine…” “H1N1 vaccine was connected with side effects… and there was this notion that there was financial interests and conflict of interests… behind its implementation… and not health safety as such…”
Policy Makers &
Public Health
Personnel
1. Views Concerning HCWs’ immunizations Public Health personnel
indicated that the following vaccines as being the most crucial:
hepatitis B vaccine, MMR, Seasonal Influenza vaccine
“HCWs should get vaccinated against Hepatitis B and seasonal Influenza vaccine… and they should do MMR as well…”
Nurses 2. Barriers -
triggers
Participants’ recognize two types of barriers concerning HCWs
immunizations:
Organizational (Lack of similar and consistent organizational
structure and practice concerning HCWs’ immunizations in
all the hospitals of the country spontaneous initiatives of
Infection Control personnel, lack of knowledge and
information provided to nurses about adult vaccinations,
Difficulties faced by HCWs concerning the delivery of
vaccines, Lack of knowledge and sensitization of Greek
patients on their rights lack of sensitization of HCWs on
the responsibility that they hold concerning the transmission
“We used to have a very dynamic team in the Infection Control Office… they took personal records of immunizations…. They informed us about booster immunizations and Hepatitis B and Tetanus… They were visiting all the Hospital’s departments and informed their personnel directly… They even remind us the time when we should do the second or the third dose of a vaccine…” “We are not against immunizations… we trust them… but we do not know which the available
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of diseases to patients) Attitudinal (Lack of sensitization on preventive initiatives
like immunizations, Work pressure & overload, Overall
sense that HCWs are well “armoured” against diseases, Lack
of sensitization on the responsibility that they hold
concerning the transmission of diseases to patients,
Ambivalent attitude of nurses, HCWs consider seasonal
Influenza a law risk disease as far as their self-protection is
concerned not as dangerous as other infection diseases,
such as Hepatitis B, Self-protection and protection of
patients against seasonal Influenza is not directly connected
with the relative vaccine, Lack of accurate knowledge and
information about its side-effects)
vaccines are… I didn’t know that there is booster immunization about whooping cough or measles, varicella… and I work in hospital for children…” “We underestimate hygiene measures… we proceed to particular actions… we wash our hands before and after patients’ examination… we are wearing mask… and we believe that we are not carriers of viruses and we won’t get sick due to hygiene measures…” We know what we will do if we were sick… in order to protect ourselves and patients’ health” “I won’t be worried if I catch seasonal Influenza… it’s only grippe… it’s not so serious… it’s not like catching Hepatitis or measles” “As a HCW I know what to do in order to protect myself and patients in case of grippe… I wear mask, I won’t cough close to patients etc…”
Physicians 2. Barriers -
triggers
Greece Participants differentiated two types of barriers concerning
HCWs immunizations: Organizational and Attitudinal.
Physicians explain lack of knowledge and information
concerning immunizations as an issue that does not belong to
the field of their specialty. They consider the general issue of
immunizations as belonging to the field of pediatricians and the
specific issue of HCWs’ immunizations as belonging to the field
of epidemiologists
Difficulties faced by HCWs concerning the delivery of vaccines
Work pressure & overload
General believe and attitude that HCWs’ immunization is not a
personal issue but an issue that the health care system should
take care of
Seasonal Influenza is not perceived as a high risk infectious
“In Greece there is no specific regulation about HCSs’ immunizations, which would be applied in all the hospitals of the country.” “I have so many thinks on my mind as a physician … and so much work to do that I would never spent time on immunizations…” “There should be inspections on HCWs’ immunizations… organized by the health care system… It’s irresponsible not to inspect immunization coverage of the health care systems’ employees. You cannot rely on physicians’ personal sensitization, willingness and responsibility to get vaccinated… Because they do not get vaccinated due to the loose system….”.
REPORT OF FOCUS GROUPS RESULTS
disease as other diseases, such as Hepatitis B
Uncertainty about the specific vaccine
“It’s a vaccine that I won’t do it … I have thought about my personal vaccinations… and not becoming contagious… but I do not include seasonal Influenza grippe in the vaccines that I’ll do in the future because I don’t think that it is so important… because the disease is not so important… it’s not so serious..”
Hospital
administrators and
infection control
personnel
Both Infection Control and Occupational Health personnel
argued on the relatively low response of HCWs on
immunizations and mentioned the main barriers as well as the
enables related to the HCWs’ immunization
Participants have identified two types of barriers concerning
HCWs immunizations: organizational and attitudinal
Lack of available vaccines
Difficulties faced by HCWs concerning the delivery of vaccines
(Administrative difficulties, financial barriers)
Work pressure & overload
Overall sense that HCWs are well “armored” against diseases
Lack of sensitization on the fact that immunizations are not
only connected to self-protection but also to the protection of
patients and whole society
Lack of specific knowledge and information concerning adult
immunizations
Negative effects on the effectiveness as well as the safety of
immunizations in general because of the communication of
H1N1 vaccine during the period of pandemic -2009 conflict
of interests concerning the launch of specific vaccine
HCWs consider seasonal Influenza a law risk disease as far as
their self-protection is concerned not as dangerous as other
infection diseases, such as Hepatitis B
Seasonal Influenza vaccine’s main competitor is the mask and
“Of course… it would be better if we had the vaccines… personnel could directly get vaccinated in the hospital… because now… it is difficult… they have to get the vaccine from an outsource… and bring it to the hospital in order to get vaccinated” “HCWs had to buy the vaccines… and that is worsening the situation…” “HCWs get vaccinated because of self-protection… they do not realize their responsibility to their patients” “There is so much work every day that it’s difficult for HCWs to compliance with immunizations appointments in the hospital… they cannot put it on their program… that the particular day I would go to infection control office or occupational health office to get vaccinated” “…they believe that the risk if they get sick by seasonal influenza is lower than any other infection disease that they could get due to their occupation…” “They don’t have specific knowledge on the seasonal Influenza vaccine… and they often connected it with pandemic Influenza vaccine…
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the specific knowledge that HCWs carry due to their
occupation concerning safety measures against risks connected
with the transition of diseases
Fear of the seasonal Influenza vaccine: Lack of knowledge,
Connection with epidemic Influenza vaccine – H1N1, Lack of
trust
There was fear during the pandemic… and its specific vaccine… the vaccine was new… and not tested…” “During H1N1 even the scientific word… the physicians… were divided into those who accepted it and those who expressed doubts about the specific vaccine… So… how could HCWs trust it…?” “A nurse said to me that she won’t do it because the last year did and was sick all the time… another one told me that she got all the symptoms… of grippe although she get vaccinated”
Policy Makers &
Public Health
Personnel
2. Barriers -
triggers
Greece 1. Organizational barriers: Lack of official framework -Law-
concerning HCWs’ immunizations, Lack of knowledge and
information provided to each hospital by official bodies about
HCWs’ immunizations exception of seasonal Influenza
vaccine due to National Campaign, Difficulties faced by HCWs
concerning the delivery of vaccines in the each hospital
2. Attitudinal barriers: Overall sense that HCWs are well
“armored” against diseases, Lack of sensitization on the fact that
immunizations are not only connected to self-protection but
also to the protection of patients and whole society, Greek
doctors’ and nurses’ lack of preventive culture, Anti-vaccination
movement, which is followed by rejection of immunizations in
general it appeals to the general population but is also
followed by HCWs, they consider seasonal Influenza a law risk
disease as far as their self-protection is concerned not as
dangerous as other infection diseases, such as Hepatitis B,
Misconceptions related to the safety of the seasonal Influenza
vaccine that generate fear of the seasonal Influenza vaccine
“There are suggestions concerning HCWs’ immunizations… yet…each hospital doesn’t receive specific regulations … Depends on the initiatives of each hospital… and how it would handle the specific issue…” “You see… Greek doctors and nurses don’t have the
specific culture that is related to immunizations and
prevention… This culture has not been cultivated
throughout their study… because all these lectures
of epidemiology… public health cover the subject
only in theoretical level… and medicine students
don’t pay much attention… and they don’t realize
its importance….”
The specific misconception / insecurity and further
lack of up-to-date knowledge generate a rather
ambivalent attitude. Consequently, there are
“rumors” and further discussions/chit-chats among
HCWs in the hospitals concerning the specific
vaccine, where physicians’ opinions play rather
crucial role,
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Nurses 3. Enablers Greece 1. Attitudinal enables: Personal sensitization of HCWs on
immunizations usually they are sensitized on specific booster
immunizations due to their occupational high risk exposure,
HCWs’ great sensitization on Hepatitis B vaccine high risk /
very dangerous occupational disease that takes the form of
serious yet common occupational accident, Concerning seasonal
Influenza vaccine the argument that enhance HCWs
immunizations is related to the protection of their family –
children or/and elder people
2. Organizational enables: Dynamic action of infection control
personnel on HCWs’ immunization: Keep personal
immunization records of hospitals’ employees, Inform HCWs’
about all kind of immunization -seasonal, booster, pandemic-
through door-to-door visits in each clinic of the hospital,
Remind HCWs the time for immunizations repetition, Door-to-
door practice, Direct communication sense of “caring” for
employees
“I was working with refugees and we all in the clinic felt quite insecure… we were not sure about the diseases that they were carrying… we discussed it and we learned that Hepatitis A vaccine would be rather good for us… since Hepatitis A is a common disease in these populations… And that’s how I get vaccinated against Hepatitis A” “We used to have a very dynamic team in the Infection Control Office… they took personal records of immunizations…. They informed us about booster immunizations and Hepatitis B and Tetanus… They were visiting all the Hospital’s departments and informed their personnel directly… They even remind us the time when we should do the second or the third dose of a vaccine…”
Physicians 3. Enablers Greece Attitudinal enablers: Personal sensitization of physicians on
immunizations due to their occupation. Although there is
information and knowledge gap concerning booster
immunizations there is the notion that they are accepted by
physicians due to their connection with childhood
immunizations there would be no resistance on doing them
alike seasonal Influenza vaccine
Organizational enables Absence of references
Hospital
administrators and
infection control
personnel
Organizational enablers of HCWs’ immunizations: Door-to-
door practice (It matched to the collective behavior of HCWs’
as it was described by administrative & Infection Control
personnel, Influence that HCWs exert over one another
concerning immunizations, Influence of role models of high
“…there is great sensitization as regards to Hepatitis B vaccine… because the risk is quite high if they get pinched with a needle…” “Again it’s their personal interests… they get immunized for personal reasons.. in order to protect
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status, such as Clinics’ Directors, it Enhance HCWs’ sense that
the “system is taking care of them” protects them
recognizes their work and contribution, Its implementation
overcomes the following barriers: HCWs’ work pressure &
overload, HCWs’ knowledge & information gap concerning
immunizations, Implementation of National Campaigns &
Official Immunization Programs (Enhance knowledge and
sensitization)
Attitudinal enablers of HCWs’ immunizations: Great
sensitization of HCWs on Hepatitis B vaccine, Regarding
seasonal Influenza vaccine protection of HCWs’ family
members, such as children and older people is a rather strong
trigger
their selves or their family and not patients…”
Policy Makers &
Public Health
Personnel
3. Enablers Greece Attitudinal enablers: Personal sensitization of HCWs
Organizational enablers: Sensitization, initiatives and dynamic
action of Infection Control personnel in each hospitals
Nurses and
physicians
1. Views Cyprus The most dangerous vaccine preventable diseases from the list
provided are Hepatitis A and B diseases, Tuberculosis and
Pneumococcal disease. The HCWs are at greater risk for the
Influenza disease, the Tuberculosis disease, the Meningitis
disease, and the Varicella disease. In reality they consider that
HCWs are at mostly at risk for the Hepatitis and the
Tuberculosis disease. Most crucial vaccines are the
Tuberculosis, Hepatitis, Tetanus, Varicella and Meningitis
vaccine. The majority of HCWs claimed that they are not sure
that the vaccine for the Seasonal influenza is useful. Moreover,
many HCWs do not consider that Influenza is a serious disease.
Some other HCWs reported that all HCWs should make
vaccines for Influenza. Some other HCWs were consciously
negative about vaccines in general. Despite that they have
reported that they strongly agree that HCWs should do
“Strongly agree with the vaccinations in general. I believe that vaccines are strongly needed to protect us” “I am personally not sure if the vaccine for the Seasonal influenza is needed. Despite that I have made it”
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Hepatitis vaccine. For all of the transmitted diseases HCWs
should be vaccinated to protect the other people. Generally
HCWs were very positive regarding vaccination and they
strongly agreed with the vaccinations, since according to them
vaccines protect HCWs. They believe that vaccines are strongly
needed to protect them.
Hospital
administrators and
infection control
personnel
1. Views Cyprus All listed vaccines are fundamental and very important. HCWs
should do all the vaccines and mainly the Tetanus and Hepatitis
B. It is for the benefit of the individual HCW to make vaccines.
HCWs need to be vaccinated since they have conduct with
people that HCWs do not know if they have any disease or the
people do know that they have any disease, it is a vicious cycle.
On the one hand the majority of the HCWs were positive about
vaccines and on the other hand most of the HCWs reported
that they do not make the vaccines. Also, it was reported that
Varicella and Influenza vaccines are not fundamental and thus
are not needed. HCWs usually make Hepatitis B vaccine and
the Seasonal Influenza vaccine. Nowadays most of the doctors
do the Pertussis vaccine. Also, HCWs frequently do the Tetanus
vaccines because they ‘judge’ that they need it and it is for own
interest.
All vaccines for HCPs should be compulsory especially that for Hepatitis. “…… vaccines for HCPs should have been compulsory ….. Especially that for Hepatitis……” HCPs should be obliged to do Tetanus only compulsorily. All the other vaccines should be done voluntarily. HCPs should be free to decide if they need to do the vaccines Vaccines should be voluntary for the HCPs “…….Seminars regarding ways of transmission of the diseases ……how easily HCPs can become sick ….. and by presenting real cases …. can be incredibly effective approach to convince them to make vaccines….. by mailing and/or handing to them leaflets would not make any different…… they will not bother to read them……”
Policy Makers &
Public Health
Personnel
1. Views Cyprus Most serious diseases for HCWs are Meningitis, Tuberculosis
and Hepatitis. Most risky diseases HCWs are Hepatitis,
Meningitis, Tuberculosis, Rubella, and Pertussis. HCWs mostly
do the Hepatitis vaccines. The most frequently vaccines done at
every department are Tetanus and Hepatitis vaccines. HCWs
are protected by the listed vaccines.
“……..HCPs believe that with the application of the safety regulations are fully protected …….especially when they treat ‘every’ patient as infected…..HCPs should always behave in that way”
Nurses and
physicians
2. Barriers-
triggers
Cyprus From all the media a huge awareness campaign was organized
which had great positive impact on the general population. At
that time also very negative comments were published about
From all the media a huge awareness campaign was organized which had great positive impact on the general population. At that time also very negative
REPORT OF FOCUS GROUPS RESULTS
the negative side effects of the vaccine claiming that such a new
vaccine should not be used. People were confused.
At hospitals not all vaccines are for free. Some of the vaccines
are very expensive. That can be a strong barrier. Some of the
vaccines are not available at the governmental hospitals
The stronger barrier for vaccinations is most often the vaccines’
cost and peoples’ ignorance and neglectfulness. Some HCPs do
not agree that the cost is the stronger barrier. They believe that
maybe nowadays that can be the case due to the economic
crisis. In the past in reality the stronger barrier was ignorance.
Information and development of awareness campaigns should
start from school.
It was reported that regulation exists regarding vaccination
among HCPs but not a law. It was said that a law should be
developed soon. HCPs especially nurses do not check-up for the
number of antibodies they have for specific diseases. Thus a law
should be developed about checking the number of antibodies
for Hepatitis and especially for HIV.
comments were published about the negative side effects of the vaccine claiming that such a new vaccine should not be used……. “People were confused …..The same situation and atmosphere was when the Hepatitis vaccine was firstly used……” Also rumours exist about economical interest on behalf of the pharmaceutical companies and speculations which end up to be the stronger barrier
Hospital
administrators and
infection control
personnel
2. Barriers-
triggers
Cyprus The HCPs who do not make vaccines usually say that they have
not thought about the issue. Generally they do not pay the
appropriate consideration for vaccines
Lack of time was mentioned as the stronger barrier
HCPs believe that they do not need the vaccines
HCPs do not make vaccines because of ignorance
Policy Makers &
Public Health
Personnel
The Health Care centres managements’ do not facilitate the
participation to seminars because HCPs have to go during
working hours. Thus the lack of time and the shortage of staff
is the stronger barrier
At each governmental hospital there is one Infection
department. Only one person is employed at that department
“……The lack of time and the shortage of staff is the stronger barrier……” “…….Nowadays suggestions are made to HCPs …..only few HCPs do the vaccines …..the majority do not pay any attention to the suggestions……only when they have accident they take action…..”
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who try to inform all HCPs. At each hospital there is great
number of HCPs and other employees and thus it is a lot of
work that is expected to be done from only one person.
The HCPs’ negative attitude about vaccines is because they do
not know and furthermore are not convinced about the
effectiveness of some vaccines, especially the new ones. HCPs
worry about the side effects
Also HCPs believe that ‘in’ the vaccines there are other
‘substances’ , not the fundamental vaccine’s substance, a
‘supplementary’ or ‘additional’ substances which may have
interactive side effects and thus serious consequences that
would have never be done by the ‘vaccine’ itself e.g.
encephalitis or neuritis or paralysis
HCPs are more often not confident for the new vaccines
Nurses and
physicians
3. Enablers Cyprus Media should not announce medical news after adjusting them
in such way to be ‘attractive’ or ‘interested’. The media’s
approach is unacceptable and it occurs almost on daily base.
Law should be developed as soon as possible. A medical scientist
or expert in the arena should be the one either to present the
‘case’ or at least to ‘approve’ what will be announced. An expert
can be a epidemiologist or a doctor who will be related with the
issue under discussion and thus s/he will tell the real facts and
reality ‘what and how was done’. Another way to announce
such serious topics is an announcement from the CDC or the
Infection Department. Only people and information coming
from these sources should be used by the media.
“ ……cleaners do not have that much academic education as the nurses or doctors who have been trained to protect themselves…….Cleaners get vaccinated and have check-ups for the number of antibodies they have just the same way as other HCPs …….” “….. regulations and/or laws must be developed for the check-up of the amount of antibodies….” “…….HCPs should compulsorily do the Hepatitis vaccine, the Meningitis vaccine and the Influenza vaccine since those diseases are more usually transmitted and more frequently found in the general population and patients particularly….”
Hospital
administrators and
infection control
personnel
3. Enablers Cyprus A national program and regulation should be developed for
compulsory vaccination for the HCPs. A strategy should be
developed for the HCPs to oblige them to do the compulsory
vaccines
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Seminars are not needed for the HCPs since they know
everything about vaccines. They only need a law to oblige them
to make the vaccines otherwise they will not make the
vaccines. Laws would be very effectual
Regulations should be developed for the HCPs vaccinations and
also for all the professionals who enable conduct with great
number of people. Prior getting a job at Health care premises or
any job relate to health issues to ask HCPs to do analysis and
check-ups
Policy Makers &
Public Health
Personnel
HCPs are more often not confident about the new vaccines.
How to deal with that barrier: provide adequate information
and updating at regular meetings. Pay particular attention about
the risks and the side effects
HCPs’ ‘neglectfulness’ is a cultural issue thus a well organized
approach is needed to deal with it.
HCPs must be reminded at times that by protecting themselves
with vaccines they also protect their patients.
HCPs do not make vaccines due to misinformation. They can
change their mind and their opinion only with the provision of
correct information. Updates about vaccines would be very
useful for the HCPs to help them decide to make responsible
decisions. Only with precise information HCPs will understand
that they need to make the vaccines
A well organized campaign should be developed particularly for
Hepatitis , Influenza and Tuberculosis diseases
A National plan for HCPs vaccines should be done by the
Ministry of Health. An awareness campaign should be repeated
every 2 years for the HCPs and the other worker at the Health
Care premises and for those HCPs who work at the ‘front line’
who ‘give’ and ‘get’ the transmitted diseases
For effective vaccinations for the HCPs a cooperation is needed
“………HCPs do not make vaccines due to misinformation …..they can change their mind and their opinion only with the provision of correct information…..” “…….A well organized system at each Health Care premise would have been more flourishing……..by checking all the personnel without exception and find out if they have done any vaccines …..Find out who have and who have not antibodies…. and then whoever would be in need will have to make the proper vaccines…..”
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at a local context among the HCPs to create a team of HCPs ,
something like a local committee to be responsible about the
HCPs’ vaccines
Nurses and
physicians
1. Views Lithuania There are 4 vaccinations paid by the employer (healthcare
facility):
Vaccination against Hepatitis B
Vaccination against diphtheria
Vaccination against and tetanus
Vaccination against flu
Vaccination against Hepatitis B is considered as obligatory for
the staff being at the risk groups (GPs, surgeons).
Vaccinations against diphtheria (once per 10 years) and tetanus
are also considered as very important.
More discussions (and less vaccinated) regarding vaccination
against flu
“I think that it is better to strengthen immunity by other means”, “By getting older I’ve started to make this vaccination each year, and I found that it works well”. So among medical professionals rejections only
Policy Makers &
Public Health
Personnel Policy
Makers & Public
Health Personnel
1. Views Lithuania Proper population immunization is a very serious challenge, so
the mechanism to improve immunization rules compliance in
healthcare facilities is needed. There is the state responsibility
to assure good performance.
Reducing coverage of children vaccination in the country
shows dangerous situation, in parallel there is a trend of
increasing morbidity.
Vaccination of HCWs is not obligatory. Vaccination of HCWs
who are in the risk group is recommended, there are routine
procedures with making lists of HCWs in risk, proposing
vaccinations and collecting signatures on their decisions.
Commonly, all HCWs who could be infected through blood and
other biological substances agree on Hepatitis B vaccination.
Differently, speaking about vaccination against flu commonly
HCWs chose the opposite positions: to be vaccinated annually
or not to be vaccinated at all.
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Criteria for the risk groups identification (flu, diphtheria,
Hepatitis A) is contacting with many people like HCWs and
teachers.
Some HCWs due to personal health etc. could not be
vaccinated. However, as a rule HCWs must be vaccinated.
Hospital
administrators and
infection control
personnel
1. Views Lithuania HCW is considered one of the most dangerous professions as
regards the risks to get contagious diseases at work. At the
highest risk remain professionals having contact with blood,
they are also exposed to viral infections and other wide variety
of infections brought by patients.
The most risky infectious diseases are: Hep B, Hep C, HIV,
other blood born infections, influenza as well as infections
resistant to antibiotics
Vaccination is a personal decision and responsibility: “a person
should be informed, and if he/she rejects a proposal to be
vaccinated, should take personal responsibility in the
infection/illness case”; “people could decide on themselves”, etc.
There are various attitudes to vaccination in society: “the people
are clearly on two sides of the fence”, “so many different
opinions”, “there is a lot of controversial information”, etc.
Nurses and
physicians
2. Barriers-
triggers
Lithuania There is no chance to prove that somebody from medical staff
had got infected due to his/her work: too difficult to reveal
relationship and no interest because of penalties from Labour
Inspection etc.
Negative view to vaccination as an exclusively private matter.
Policy Makers &
Public Health
Personnel Policy
Makers & Public
Health Personnel
2. Barriers-
triggers
Lithuania A lack of money in healthcare facilities could explain
insufficient vaccination.
Necessity to pay for vaccination is a barrier.
There is a lack of information about real situation in the field of
immunization. There is a lack of information about real cases of
diseases and even deaths of non-vaccinated people in opposite
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to the big flow of negative information on adverse effects of
vaccinations and so on. There is very difficult to register
professional diseases both because it is difficult to prove a
causality and due to an interest of employers to hide the cases
(to avoid penalties, etc.). Employers are interested to avoid
registration of accidents with transmission of infections in
healthcare facilities.
Public health specialists are not active or do not manage proper
tools to promote immunization.
There is a lack of awareness among young public health
professionals because of gaps in their education (due to the
recent changes in curriculum): New graduates have relatively
less knowledge in epidemiology.
Polyclinics (pediatricians) and GPs are not active in proposing
vaccinations (with some exception in a flu case). GPs replaced
pediatricians and GPs likely are not so strong in vaccination’
promotion.
Population is quite passive and skeptical about vaccination
against flu, even both free of charge and advertising by
polyclinics vaccination do not attract many peoples, and
commonly they say “I do not get ill”. There is a lack of
information about modern vaccines, many people still live with
their knowledge and understanding acquired many years ago
and do not mind that situation had radically changed. People
also remember previous situation (with Pertussis vaccination)
when they were proposed optionally to be vaccinated with one
vaccine free of charge (paid by the state) or another – better one
to be paid by the patient, so they could conclude that they are
proposed something of low quality.
Some NGOs are much more effective in disseminating negative
(often outdated or not evidence-based) information than
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HCWs, because they learned how to do it and they are active.
There is a lack of information about vaccination requirements
in other countries: people should know that, for instance, they
or their children could have fewer opportunities for education
or job in some countries if not meeting vaccination criteria.
Hospital
administrators and
infection control
personnel
2. Barriers-
triggers
Lithuania General public has a lack of medical information on
immunization against infectious diseases. There are health care
professionals, who are not interested in medical updates as well
and are behind contemporary knowledge and do not
recommend vaccinations to their patients and do not get
vaccinated themselves.
Reduced access to vaccination in Vilnius. There was an
immunization unit at Lithuanian Communicable Diseases and
AIDS center in Vilnius (on the way from the city center to our
facility). It had been recently closed. Now all people should go
to GPs to get vaccination.
Not sure in GPs capacities to manage the deal. It creates
additional workload for GPs). GPs are overloaded with their
current job.
Not all facilities likely have and enforce clear rules on
immunization of the medical staff.
No immunization campaigns either on a national or on a
regional level ever have been recorded by any of the FG
members. In general more reliable information on benefits of
immunization should be produced and distributed by public
health centres.
Lack of research: Single study aiming to identify the level of
knowledge and attitudes of health care workers towards
vaccination from flue was mentioned. Researchers concluded
that HCW are rather well informed about vaccination from flue
though only 30% of them got vaccinated from flue themselves.
”After closing the immunization unit, we already observed that more people are coming for getting vaccination” “we never have sufficient number of influenza vaccines for general public, therefore nation-wide immunization campaigns would be in vain since we wouldn’t have anything to inject them”
REPORT OF FOCUS GROUPS RESULTS
The main reasons for negative attitudes towards vaccination are
uncertainty about safety and effectiveness of vaccines as well as
a distrust to the information provided by the state health care
authorities about vaccines
Nurses and
physicians
3. Enablers Lithuania There is national legislation (Minister of Health Order) for
employers (healthcare facilities) to provide vaccination for
medical staff against infections they could be contaminated.
There is an obligatory reporting on vaccinations.
There is an obligatory reporting on adverse effects. The data on
adverse effects is reported to the State Pharmaceuticals Control
Service.
Learning from good practices: There is a good practice in the
USA that if there is a possibility to prevent infectious disease by
vaccinating an employee and one refuses to, but afterwards gets
infected; all treatment costs should be covered by the employee
himself/herself. Maybe we should follow this example and
introduce an obligatory vaccination as we have obligatory
health check ups at work - if one prefers to work as a HCW in
health care institution, he/she should get vaccination against
Hep B and influenza at least.
Policy Makers &
Public Health
Personnel
3. Enablers Lithuania There are particular institutions in charge of communicable
diseases control. Their employees consult people, particularly
on vaccinations regarding travel abroad.
According to legislation, there should be a public health
specialist at healthcare facilities in charge for identification risks
groups and lead/control vaccination procedures.
Regulation requires registering all cases of infection
transmission at healthcare facilities; this registration serves to
prove professional diseases or injuries.
Dissemination information about real cases of diseases and even
deaths of non-vaccinated people by medical professionals.
REPORT OF FOCUS GROUPS RESULTS
Making information campaigns in schools could be effective.
Possibly an interest of pharmaceutical companies could be used
in promotion vaccinations, and it actually happens.
Nurses and
physicians
1. Views Poland Vaccine purchasing
Doctors vs. nurses (There is a breakdown - nurses vaccine
themselves more likely then doctors do – moderator; Due to the
fact, that there is a lot of threats in the clinic, there is a
decision about the vaccination)
Caring for hygiene
Significant role of the GP
Financial responsibility for vaccination should be on the
employer’s side
Actually, we are buying the vaccine and it is financed by social services and it is completely free for workers or it is available for a small charge We started to realize, that health is the foundation of life – moderator; Our health rally depends on natural conditions … and I would say - I would have seen the significant role of the GP – 1; No one can notice it. This is the crucial matter – the role of GP -1 Vaccine should be refund by employer. It is employer’s liability -2; In Labor Code we can find different legislation acts and relevant regulations which inform us, that employer is obliged to make any efforts to protect employee from dangers in the work place. [Influenza] is poses a risk to employee. It is employer’s duty to protect employee from danger -2)
Policy Makers &
Public Health
Personnel
1. Views Poland Keeping vaccine in bad conditions
City has no possibility to buy vaccine
Lack of health culture
Lack of information concerning vaccination among employers
Individual approach
I Think it is laziness. Thinking – maybe tomorrow, maybe day after tomorrow and the whole season goes; In my opinion a lot of people are too much self-confidence. And in this way they threaten their environment – 1; Fortunately, there are only few people who are uncritically. It is only handful of people I am not talking about cold chain but this matters with drug store – 1; But if this vaccine is bought in so-called cold period, and it is wrapped in and isolating barrier of air, and we transfer it into home
REPORT OF FOCUS GROUPS RESULTS
directly from pharmacy, and at home we put it to the fridge or refrigerator – and it is not bad Yes, because we are not buying. We always give the money, but in fact we only pay. In fact, we as city cannot buy vaccines. There is no formal way to buy it Employers are not well informed when we are talking about vaccination in Poland – Mrs3; Some of employers want to be well informed, but they don’t know how to achieve it. They see only problems (So, it must be something what in medicine is so-called individualization of the medical treatment to the subject – moderator; And the conclusion, that approach is much more centralized than diversified. It’s better to solve problems in macro scale
Hospital
administrators and
infection control
personnel
1. Views Poland There are vaccines, which most people consider to be necessary
Flu and the flu vaccine - a source of controversy
Lack of education Hepatitis as mandatory vaccination for
employees
Lyme disease - a fashionable topic
Sometimes there is no discussion and everyone agrees that there are some vaccinate which are obliged - i.e. vaccine against tetanus- 1 We cannot generalize the concept of vaccination – we have very individual needs (and this is why I think, that that we cannot generalize everything, we have to specify it first – 1) (The things are in different way with flu, because there is a lot of controversy – 1; Doctors consider danger of flu in different relation to each other and different for patients – 1; They believe that they working for so long they have the immunization on that level, that undoubtedly they are no longer threated. What is more, they are afraid that if the vaccinate themselves they will be sick more often. And then they have total blockade - 1)
REPORT OF FOCUS GROUPS RESULTS
(But I think that main problem today is education – 1; but this is only a superficial knowledge, somebody said something on TV – 1; In our, doctor’s environment hardly anyone reached a publications – 1; And it lingers on all the time – there is no sense to vaccinate if I am not sure how and what kind of virus will infect us. And this opinion is often repeated. And what is more, someone will suddenly say: I was vaccinated last year, and after all I was totally sick -2) (for example, now Lyme disease makes a career - 2, No, unfortunately at the moment we have to be sick on Lyme because vaccination is not very effective - moderator)
Nurses and
physicians
2. Barriers-
triggers
Poland Reportability vs. real use of vaccines
People are getting sick after vaccination
Financial issues
Carelessness among doctors, lack of awareness concerning
vaccination
Keeping vaccine in bad conditions
Too many duties among doctors
Lack of the knowledge of the law
Lack of training among doctors
Lack of education
Prevention among employees after working hours
Lack of information concerning healthy life
It is hard to find information where vaccination take place
I was instilled once, and then I was sick for long time – 1; Or – I will fell sick after vaccination. But I don’t have time to be ill – 1; When we heard something about particular vaccine, we usually transfer this information on all vaccines Yes, we have financial problem here – moderator; I am sure, that if employer refund total price of vaccine almost 98% people would be vaccinated – 2; When employee have to add 10 zloty to vaccination he is not interested in this business. But if he has to pay total price – almost anyone would be vaccinated – 1) It wouldn’t happen to us. This is on this principle. And now, doctors’ responsibility is much more higher than it was few years ago -1
Policy Makers &
Public Health
2. Barriers-
triggers
Poland
Lack of responsibility among doctors (rush, lack of time.
Reportability vs. real use of vaccines
Nobody reminds, I suppose We announce campaign in October, and during
REPORT OF FOCUS GROUPS RESULTS
Personnel whole October we receive money for vaccine – 1; But whose who register for vaccination are not surely to come; They pay whenever they want to pay. He paid, he will be vaccinated – moderator; Money should be on the bank account until this day. You have money – until today we have so much. Since today vaccines will be just a little more expensive because I have to order new once – moderator; I think it would convince some people to vaccination
Hospital
administrators and
infection control
personnel
It is hard to persuade people to flu vacation Lack of education
Media as an opinion-forming medium
Lack of awareness according vaccination
Medical market depends on financing, importance of
advertisement concerning vaccination.
Financial barriers
Lack of responsibility for vaccination among doctors
Lack of prevention
Lack of authorities
But I think the main problem, however, is education now; First of all we should concentrate on question – what we should do to convince our environment to vaccinate, you are exposed to diseases, why you have any doubts that you should be vaccine? Report ability is great, but what am I going to say – there is still financial barrier; there is financial barrier
Nurses and
physicians
3. Enablers Right path
Trainings for nurses and physicians
No, no – nurses are responsible for vaccination; We have immunization coordinator. He is responsible for vaccination but also for other issues concerning this matter; Doctor qualifies for vaccination; Doctor qualifies for vaccination, but coordinator is responsible for promotion, orders etc. Nurses take part in immunization training all the time, they improve they knowledge according to vaccination problems; Doctors have very similar trainings
Policy Makers &
Public Health
3. Enablers Poland Social-economic studies as grounds for vaccination model. This population, we have to know how much we have in this population, how often people were
REPORT OF FOCUS GROUPS RESULTS
Personnel vaccinated, we have to perform “screening” concerning all this information, what has happened with them. And then we will see what we have to do. When we will know, what we have to do, we have to ask next question – how much money we have?
Hospital
administrators and
infection control
personnel
To create internet portal
To conduct a Survey
And this is how we have talked about it. And I think that we should agree, that firstly we have to create internet portal; Without internet, there is no way to do anything; And the best idea is Internet – everyone can log on and fill in the questionnaire
Nurses and
physicians
1. Views Romania Positive attitude regarding vaccination:
low transparency and poor communication of the national
strategy regarding immunization
poor coverage of migrant populations or particular populations
groups at risk ( low educational level, socio-economic
conditions extremely low, population living I isolated
geographical areas
budget under financing
low information about pharmaco vigilance
low information about the complete vaccination schemes
Communication tools:
Inefficient, lack of information campaign regarding the benefits
of immunization
Lack of Burden of vaccine preventable diseases awareness
among the general public
Media has an important role in supporting the process /
vaccination benefits awareness among general public
Positive attitude regarding vaccination: Compulsory
immunization scheme should become part of a long term,
coherent public health policy
REPORT OF FOCUS GROUPS RESULTS
Physicians were reluctant in general in talking about
immunization (they consider to be very knowledgeable with
regard to this issue, especially with regard to the immunization
of HCW; they do not know very well the legal framework for
HCW; besides immunization for Hepatitis B and influenza, they
do consider that other immunizations are necessary only for
doctors working in infectious diseases departments
(pneumococcus/ varicella/ etc).
Difficulties in reporting on immunization (both to SIUI and to
the RENV); difficulties in validating performed immunizations
(especially for the children 0-6 month)/ lack of compatibility of
softwares used in PHC with SIUI/ software of the RENV
Policy Makers 1. Views Romania Decentralization of health care institutions and fragmentation
of the services provided by the District Health Authority;
Low levels of funding deployed through more sources of
funding/ The existence of several sources of funding creates mal
-functions
Legislation in place concerning the HCW immunization
:guideline, services, budget , communication strategies, control
mechanism
Should be part of a national program: HCW is a population at
risk for VPDs: INFLUENZA, Tuberculosis, Measles, Mumps,
Rubella, Hepatitis B, Diphtheria, Pertussis
Mandatory to be implemented at the institutional level
depending the type of medical services delivered;
Assumed by the institution management
Mandatory vaccination linked with the employment process
Vaccination process should be conducted in a controlled way
Epidemiological department for each institution responsible for
vaccination guideline implementation;
Lack of leadership at the level of the National Immunization
REPORT OF FOCUS GROUPS RESULTS
Programs;
Low immunization coverage of the population at risk
Hospital
administrators
1. Views Romania Lack of inter sectorial approaches with other sector ministries
(i.e. education, administration and interior, etc) when talking
about immunizations;
The population knows the risks of vaccines, but does not know
the risks of non immunization;
Lack of control of information that promotes non vaccination.
Lack of transparency of immunization policies;
Dysfunction in procurement of vaccines;
Dysfunctions in ensuring the chain of cold at local level;
Malfunctions within structures that ensure pharmacy vigilance
HCWs - Vaccination should be done at the healthcare
institutional level, and should have the following
characteristics: Mandatory vaccination should be managed by
each healthcare institution for its employees; Employee Ac
screening should be mandatory; local guidelines should be
implemented; Periodical trainings should be conducted;
Vaccination process should be conducted in a controlled way;
Epidemiological department for each institution responsible for
vaccination guideline implementation
Nurses and
physicians
2. Barriers-
triggers
Romania The lack of communication regarding the vaccination benefits
to the general public
National Immunization Programs – budget under financing
Policy Makers Lack of information, training – lack of knowledge or adequate
information about disease exposure
Lack of time;
Budget allocated insufficient; lacks predictability
The process is not well organized, structured
Lack of commitment of personnel compulsory HCW
vaccinations
REPORT OF FOCUS GROUPS RESULTS
Lack of existence of a mandatory epidemiology specialty MD
for each institution
Attitudinal related barriers: fear of side effects, beliefs that these
types if workers are not at risk
Hospital
administrators
Lack of information, training – lack of knowledge or adequate
information about disease exposure
Lack of time
Lack of money
The process is not organized, structured
Lack of commitment of personnel compulsory HCW
vaccinations
Lack of existence of a mandatory epidemiology specialty MD
for each institution
Attitudinal related barriers: fear of side effects, beliefs that these
types if workers are not at risk
Nurses and
physicians
3. Enablers Romania
Policy Makers 3. Enablers Romania Increase institutional capacity for implementing and
monitoring the nationwide immunization programs; increase
project management capacity of such institutional structures;
deliver founding through only one source of funding (public
funding)
Measures shall be taken to increase the appropriateness,
predictability of one source funding (source- state budget);
gradual increase of multiannual budgeting in the coming years)
of the National Immunization Program
Hospital
administrators
3. Enablers
Nurses and
physicians
1. Views Germany Vaccinations are of high personal relevance due to the family
Lack of knowledge/ disinterest among the population
Vaccinations are rational for certain groups
“I think it is an important topic but it is a fundamental personal attitude… for that reason it has always been important for me to protect myself
REPORT OF FOCUS GROUPS RESULTS
A lot of people are hostile to vaccinations
High level of skepticism regarding vaccinations against
influenza
Lack of risk awareness
The attitude of the general population does not differ from that
of HCWs
in this regard, not only me but my family…”(N), “I am a bit more careless because I do not have a family in the background”(N), “… since I became a father I became more sensitive and informed about current vaccinations… beside that: vaccination against influenza have never played a role for me”(N) „Apart from that I think that there is a great lack of knowledge and disinterest among the population unless it is urged in some cases. That is my impression and there is less promotion in this regard… “I think it starts with the counseling of children and should be emphasized in the occupational medical service. These would be the right places to make it popular.“(N), “… it depends on the social class… you can observe the socially underprivileged who are careless regarding “U-Untersuchungen” (preventive check-ups for children) and maybe also regarding vaccinations. On the other hand there are – let’s call them intellectuals – who are strictly against vaccinations.” “I think that most people oppose vaccinations…”, “Without trying to discourage you: regarding vaccinations you can do what you want, it will not have any effect.”, “That means: the general attitude in the society is not pro-immunization at all!” „… for me it (infectious diseases) is not a threat and I only do what is a threat for me… and the threat is not real for most people.”, „… those who do not vaccinate their children hope or build on the hope
REPORT OF FOCUS GROUPS RESULTS
that all the others are vaccinated…”, “… there is no immediate threat.”
Policy Makers &
Public Health
Personnel
1. Views Germany Vaccination is considered to be important
Lack of knowledge/disinterest regarding vaccinations of HCW
“…for me vaccination is an important part of prevention. Prevention, because it is a relatively cheap way to avoid serious diseases or serious courses of disease, to avoid death…”, “Basically I have a positive attitude towards vaccinations. I am sure that the basic vaccinations for babies and infants are necessary, booster injections are also important. I am ambivalent in regard to HPV-vaccinations or vaccinations against influenza …” “Not everyone, I think that regarding vaccination against influenza more than half of them, about 60%, do know about it or ignore it…”, “This is truly the case because medical practitioners think they are special and medical practitioners do not catch a disease.”
Hospital
administrators and
infection control
personnel
1. Views Germany Vaccination coverage rate depends on media coverage
(particularly vaccination against influenza)
Consultation on immunization at the general practitioner is not
sufficient
Differences between East and West (of Germany)
“Vaccinations are only covered if something is supposed to have happened. So– to take this example again because this is the attraction here – serious multiple sclerosis due to vaccination. Paralysis of the body caused by vaccination against hepatitis B for example. Things like that are covered by the media which is counterproductive, everything else is not covered by the media”, “I think, but cannot prove it, that no general practitioner has sufficient time for consultation on immunization. Not to the extent necessary to rebut counter arguments. For that reason we refer to other structures – … - which have to make time for that. For example the vaccination center of the
REPORT OF FOCUS GROUPS RESULTS
health department and most probably the vaccination centers of health departments in general. They focus on nothing else.” “I think today there is still a difference between East and West. In former times it was tightly organized and it was accepted. I am talking about vaccinations against childhood diseases etc, today it depends on self-initiative…”
Nurses and
physicians
2. Barriers Germany Pseudo-knowledge / lack of knowledge influences decisions
Lack of risk awareness
Individualistic society
Attitudes of paediatricians and general practitioners
Presentation in the media
Fear of vaccinations/injections/needles
Effort of money and time
Insecurity regarding the efficacy of the vaccination
“Among the population there is a lot of pseudo-knowledge about ingredients, about what could happen and what could not happen” „Above all it is the lack of fear of the appearance of these diseases because they have not appeared for years.”, “It is not an actual danger.”, “For most people buying GM corn is an actual danger but a missing vaccination is not.” “But that is a problem of the individualistic society, again…”, “… if you enrol your child in kindergarten you have to get a declaration of no-objection from the paediatrician… at the communal kindergarten you have to. If you have to submit it you can tick it: harmless... let’s say: not immunized. In my opinion this is twofold because if you bring your one-year-old child there not all it is not vaccinated against everything… „If you take the last vaccination against swine influenza as an example, it was badly presented in the media or badly communicated, different vaccines for different occupational groups and officials, this causes insecurity. In the end the predicted wave of infections did not happen,
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particularly in our region there were only a few cases. Then, of course, the immunized person wonders if the vaccination really was necessary. Was it really worth it?” „… most people are scared of the vaccination, scared of needles or the injection…”
Policy Makers &
Public Health
Personnel
2. Barriers Germany Media coverage
Finances
Information
Responsibility/guidelines
Ignorance or lack of knowledge influence decisions on
vaccination
Lack of risk awareness
“Media coverage is a factor. And the media – there are some media covering vaccinations in calmer periods but in general they cover it when it already is too late.”, “I also think that the media, including conservative weekly journals which are expected to have high quality content, often cover conventional medicine in a very negative way…” … it occasions cost if there is no name of a pharmaceutical company on the packaging and usually none has the money…” “But to which extent is this information available for patients? Without requiring great efforts on behalf of the patient. The patient will not search for this information in professional publications. In general they are too sophisticated for the general population.”, “There are many aspects and sometimes I talk to skeptical parents often resulting in 50/50. Mostly it takes an hour or even longer and that cannot be done by the pediatrician.” “… there are too many players in the game regarding finance as well as organization. This makes the whole thing more difficult…”
Hospital
administrators and
infection control
2. Barriers Germany Vaccination coverage rate depends on media coverage
(particularly vaccination against influenza)
Uncertainty regarding cost absorption/ finances
“Vaccinations are only covered if something is supposed to have happened. So– to take this example again because this is the attraction here –
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personnel Different recommendations on vaccination in different
countries/states
Fears / Insecurities
Complicated accessibility to vaccinations at the general
practitioner
serious multiple sclerosis due to vaccination. Paralysis of the body caused by vaccination against hepatitis B for example. Things like that are covered by the media which is counterproductive, everything else is not covered by the media” „Another question is: how much does the health insurance pay? That really is a problem!“ „… the recommendations on vaccination in other states… it is not harmonized...”, „I do not visit my general practitioner, who belongs to dying species, if I have to wait for three hours, this discourages me, I don’t accept waiting.”
Nurses and
physicians
3. Enablers Health insurances
General practitioners and pediatricians
Media
„Meanwhile it takes place again, in particular on behalf of the health insurances and the AOK.” „The general practitioners would be the persons to address.”, „And who could inform you about that? – general practitioners.“, „ You get well informed by the pediatrician but always with the message that it is your own decision. That is a bit inconclusive.” „No, in general people are annoyed by the way it is presented in the media, particularly if it is done in a lecturing way.”
Policy Makers &
Public Health
Personnel
3. Enablers Germany Vaccinations should be covered by the media in a less
sensational but realistic or positive way.
Distribution of information on the national level or on the
federal states level is reasonable.
A uniform design of recommendations regarding vaccinations is
advisable.
Public health offices / vaccination centers could take a greater
share regarding vaccinations.
Midwives are a good access point to young parents.
„You could motivate a lot of patients and the population to get vaccinated with the help of the media. But also by avoiding negative reports on academic medicine and making objective reports.“, “And if a Ministry of Health wants to do health promotion, prevention in the first stage, you can think about presenting these webpages in a way attracting the reader.” „Yes, but if we think of a well functioning public
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health office here in XXX, let’s say if we are 10 people carrying out vaccinations we cover about 50% of all vaccinations, today we are only covering 1 or 2%.”
Hospital
administrators and
infection control
personnel
3. Enablers Institutions can contribute to the opinion-making regarding
vaccinations through various activities (especially information).
Optimization of the counseling offered by the
employer/company physician.
Health insurances can be supportive, for example with the help
of reminders, financial incentives.
Vaccinations should be presented less sensational but realistic
by the media: perhaps emphasizing complications in
consequence of missing vaccinations.
GPs and pediatricians are important contact persons for
vaccination and should be convinced of vaccinations.
„…here, you are getting informed about offered and recommended vaccinations, often against the backdrop of journeys or in the form of questions: Which one would be the next vaccination for my child?” „…if we have a training on infectious diseases we are always referring to these vaccinations. What kind of prevention the medical personnel needs, and for us the recommended vaccinations are defined.”
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55
Suggestions
Greece
1. Enhancement of knowledge and sensitization of nurses on immunizations trough:
compulsory educative lectures on HCWs’ immunizations
the provision of electronic and printed material -pamphlets- containing information on immunizations
for HCWs. They would contain up-to-date knowledge and information about the following issues:
available vaccines for specific diseases, years of protection, specific time that booster immunization are
needed, relevant antibodies examinations and cost of the vaccines, sending personal e-mails to HCWs
concerning immunizations that enhance personal sensitization of HCWs. Yet, there are no personal e-
mail accounts for HCWs in all the hospitals. The door-to-door practice will enhance sensitization of
HCWs collectively. Posters about HCWs’ immunizations would be an initiative that generates negative
reactions. Dissemination of knowledge and information that is not appropriate for Professionals.
Connotation of marketing ways of promotion that contradicts to scientific knowledge. Change of the
issue from personal into collective through the establishment of an office in each hospital that would be
responsible for HCWs’ immunizations. Personal e-mails from the Medical Association. Facilitation of
the access to information and knowledge regarding booster immunization. HCDCP is considered to be
the reliable official body that could offer such information and knowledge.
2. Overcoming organizational barriers concerning HCWs’ immunizations through:
Generation of a strict framework concerning HCWs’ immunizations that would turn immunizations
into a “must”, “duty” of HCWs and would overcome the barrier of HCWs’ work pressure and overload.
For the physicians it would turn HCWs’ immunizations from an issue of personal choice and free will
into a “must” -something “necessary”-, that becomes not only a professional duty of HCWs but also a
duty of the health care system
Since yet, there are participants who question the obligatory nature of immunizations. Development of
a professional health booklet and portfolio that keeps records on HCWs’ personal immunizations and
informs personnel about the next immunization appointment. Promote of an easier way of vaccines’
distribution that overcomes the barriers concerning prescription and cost of the vaccines.
3. The practice of infection & immunization indexes for each clinic of the hospital generates rather
controversial responses
Nurses seems to be more favourable towards infection indexes, since their information about the
occupational risks would be enhanced
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56
Concerning immunization indexes participants: are rather indifferent, since they do not realize direct
connection between immunization and infection indexes and are quite negative, since they consider it
as disincentive, “You don’t gain anything through shame… through stigmatizing a whole clinic as
regards to immunizations… this is not nice… It is better to make vaccinations obligatory… rather than
make somebody feel embarrassed for its immunization history…”
Italy
There is a need to increase vaccination coverage among HCWs and in order to reach this objective, it
is important to provide scientific information, conveyed with appropriate tools. Integrated communication
activities, customized and based on a two-ways communication are deemed essential for the dissemination
of reliable information among the health staff. Implementation of training activities, based on an accurate staff
need assessment is one of the most efficacious interventions that Institutions can use. Active versus passive
approach and the availability of free access informational and educational sessions are recommended by some
participants.
For several participants immunization should be a pre-requisite for health professionals working in
the health sector. There is a need for the distribution of National Guidelines or protocols that could be easily
implemented at local level, as well as to assure the availability of dedicated economic resources. From an
organizational point of view, one of the most interesting suggestions is the identification of the occupational
physician as a key person for promoting the check of vaccination status of health workers. The argument
“some vaccinations should be compulsory for staff working” needs to be thoroughly discussed.
Cyprus
There is a need to develop a national program and guidelines for compulsory vaccination of the
HCWs. A strategy should be developed for the HCWs to force them to uptake the compulsory vaccines.
Seminars are not needed for the HCWs in Cyprus since they believe they know everything about the
vaccines. They need a regulation to force them to uptake the vaccines otherwise they will not do it. Laws
would be very effectual.
Regulations should be developed for the HCWs’ vaccinations and also for all the professionals who
enable conduct with great number of people. Prior getting a job at Health care premises or any job relates to
health issues HCWs should perform all the check-ups. A ‘pressure’ must be developed in a form of ‘verbal
warning’ and then ‘written warning’ to the HCWs and a copy must be sent to the top management if any
HCW has not made the proper vaccines. If supervisors at each Health Care premises were evaluating the
applicability of the vaccine protocol then HCWs would have been more protected and thus the protocol
would have been more successful. There is a need to ‘face’ and deal with all HCWs’ ‘reasons’ and hesitations
REPORT OF FOCUS GROUPS RESULTS
57
and try to eliminate them. The opinion leaders from the Ministry of Health must make announcements
regarding the topic and develop awareness about vaccines.
Physicians should put outside their door an announcement informing people that as physicians they
have done Hepatitis vaccine. Also media can be help to eliminate the ignorance about vaccines with
qualitative documentaries explaining things using simple language about ‘what’ vaccines are and ‘how’ they
function. Especially nowadays it is important that the most important vaccines are provided free of charge.
Lithuania
Clear rules for immunization schedule should be established by the employer (annually a list of
employees who are proposed to be vaccinated is issued according to the risk groups, everybody should sign
it with “yes” or “no” about flu vaccination). People should know who is responsible for vaccination. HCWs
within the institution should be divided into two groups as mentioned above. Institution would provide
vaccination to all the staff on request with the flu vaccines for free since vaccination costs are covered by
Territorial Health Insurance Fund. Hepatitis B vaccine is also recommended to the professionals who have
direct contact with blood, but HCWs have to share the cost for the vaccine since the HC institution covers
only 50% of the cost.
There is a good practice in the USA that if there is a possibility to prevent infectious disease by
vaccinating an employee and one refuses to, but afterwards gets infected, all treatment costs should be
covered by the employee himself/herself. This could be a good practice to increase vaccination coverage.
Vaccination against flu is providing in a “passive” way and more staff refuses to vaccinate. It is
essential to assure convenient arrangements for vaccination at the facility. Public health professionals
(epidemiologists) should be more involved.
GPs should be more active in promoting vaccination to the population (mainly to those age 26+ re-
vaccinations against diphtheria, annual vaccination against flu, etc). Professional advice is needed as
information provided mostly from mass-media is not adequate. In general, public health institutions should
provide information to the general public and HCWs on immunization topics via mass media, special
workshops and public activities. Ministry of Health should also be preoccupied with immunization problem
occurring in general public.
Poland
In order to increase the vaccine coverage there is a need for the provision of individualized care
approach. Educational lectures to enhance vaccination awareness.
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58
Romania
Media has an important role in supporting the process / vaccination benefits awareness among general
population.
Compulsory immunization scheme should become part of a long term, coherent public health policy.
There is a need to organize communication campaigns tailored for the specific institutional needs, to
conduct Ag screening campaign among HCWs, to conduct mandatory vaccination for HCWs prior to their
enrolment and develop a National guideline concerning vaccination: influenza, Tuberculosis, Measles,
Mumps, Rubella, meningococcal disease, Hepatitis A, Hepatitis B, Pneumococcal diseases, Tetanus,
Diphtheria, Pertusis.
Germany
Some of the suggestions are the following:
Vaccinations should be covered by the media in a less sensational but realistic or positive way.
Distribution of information on the national level or on the federal states level is reasonable.
A uniform design of recommendations regarding vaccinations is advisable.
Public health offices / vaccination centers could take a greater share regarding vaccinations.
Midwives are a good access point to young parents.
The population should be sensitized regarding the risks of VPDs.
The impact of financial factors on the area of vaccinations should be reduced.
Information which is objective and easy to understand should be easily accessible.
The responsibilities/regulations/finance regarding vaccinations should be clarified and communicated.
Physicians have to be confident of vaccinations and should have enough information in order to advise
and inform patients in a comprehensive way.
Physicians have to be confident of vaccinations and should have enough information in order to advise
and inform patients in a comprehensive way.
Students of medicine have to be confident of vaccinations and should have enough information in order
to advise and inform patients in a comprehensive way later on.
There is a strong agreement on the implementation of mandatory vaccinations.
A regular check of vaccination cards and reminders regarding vaccinations are viewed as reasonable.
DISCUSSION
This study involved a convenience sample of 282 HCWs from several hospitals and other settings.
Factors such as errors in recall and social desirability response tendencies, for example saying ‘what sounds
correct’, may make it difficult to generalise the findings of the study. Therefore the sample composition is
representative of the views and the attitudes to immunization among HCWs in seven countries. The study
REPORT OF FOCUS GROUPS RESULTS
59
provides valuable insights into some aspects of what HCWs know, think and feel about immunisation and
how they act and behave. Although there are some differences between the participating countries relating
to the views and the suggestions of the HCWs for improving adherence with vaccination uptake, there also
some similarities on their attitudes.
Views of the HCWs regarding vaccination
Despite the recommendation by WHO, endorsed by many European countries, uptake of influenza
vaccination in healthcare workers varies. In general the HCWs of the sample have emphasized the
importance of immunization and were favorable to their vaccination and that of the public. Many of them
were familiar with the booster immunization program. The vast majority of the participants considered that
HCWs belong to the high risk groups for acquiring a vaccine preventable disease. Some countries suggest
the compulsory vaccination of the personnel through a national program whereas other countries claimed
that in order to increase the vaccine coverage there is a need for the provision of individualized care
approach. For several participants immunization should be a pre-requisite for working in the healthcare
sector. There is a need to develop National Guidelines or protocols or a National Strategy that could be
easily implemented at local level, as well as to obtain the necessary budget.
Hepatitis B is considered to be the most important vaccine preventable disease given that is the more
common occupational risk mainly after a needle stick injury. The vaccination still remains the most
effective preventive measure against vaccine preventable diseases.
Need for education
Educate healthcare workers about the benefits of influenza vaccination and the potential health
consequences of influenza illness for them and for the patients is essential. The majority of the participants
claimed that there is a lack of knowledge or insufficient and incorrect knowledge and evidence based
information for the benefits of vaccination that may explain the lack of vaccination awareness. In some
cases there is a lack of awareness among the young public health professionals because of gaps in their
education as new graduates have relatively less knowledge in epidemiology. The information and awareness
campaigns should start from the school age. These campaigns should consider the role of Mass Media in
public opinion formation or change. The role of media, internet blogs is still significant, especially in
affirming attitudes and opinions that are already established.
In some cases the valid and reliable information is sparse. On the other hand the information that is
provided from the mass media is not the adequate as it causes a misunderstanding and may be responsible
for the low vaccination awareness of the public. Some countries have emphasized the need of compulsory
educative lectures on HCWs’ immunizations. These lectures should be “interactive” based on electronic and
printed material -pamphlets and posters- containing information on immunizations for HCWs. They should
REPORT OF FOCUS GROUPS RESULTS
60
contain up-to-date knowledge and information about the following issues: available vaccines for specific
diseases, years of protection, specific time that booster immunization are needed, relevant antibodies
examinations and cost of the vaccines, sending personal e-mails to HCWs concerning immunizations that
enhance personal sensitization of HCWs. The lectures should give an emphasis to both personal and family
protection as these two facts influence the decision of the HCWs to have the vaccine. The educational
programs should enhance the confidence of the HCWs to the benefits of vaccination. Physicians have to be
confident of vaccinations and should have enough information in order to advise and inform patients in a
comprehensive way.
Needs of the HCWs
The majority of the participants claimed that they need specific information about the different
vaccines, as well as about the importance of vaccination in the prevention and health protection. They also
need reliable data on VPDs incidence, vaccination coverage, incidence of sequelae, of gaining knowledge
e.g. through specific seminars and toolkits, of appropriate premises for administering vaccination in
hospitals. The main benefit includes protection of both HCWs and patients.
It is essential to develop a strict framework concerning HCWs’ immunizations that would turn
immunizations into a “must”, “duty” of HCWs and would overcome the barrier of HCWs’ work pressure and
overload. This framework should include the output of the current research (the barriers, the enablers, the
cues for action reported from the HCWs).
Attitudinal barriers for the uptake of vaccines
Some of the attitudinal reasons that explain why HCWs do not receive vaccination are the followings:
fear of injections, lack of information and knowledge about the booster vaccines schedule, did not imply
that they had a moral duty to accept vaccination, lack of knowledge about the benefits of vaccines,
physicians do not recommend vaccination to their patients, belief that HCWs’ immunization is not a
personal issue but an issue that the health care system should take care of.
Organizational and institutional barriers for the uptake of vaccines
Some of the organizational and institutional reasons that explain why HCWs do not receive
vaccination are the followings: busy schedules, cost of vaccination, the current policy of voluntary
vaccination of healthcare workers, lack of prevention culture, lack of prevention strategies, lack of
authorities’ commitment to vaccination, lack of accessibility to vaccines for the vulnerable population,
different immunization schedule among the EU countries, lack of an expert in epidemiology in each hospital
and the existence of an anti-vaccination movement after the experience of H1N1 pandemic in 2009, lack of
a consistent organizational infrastructure and clinical practice concerning HCWs’ immunizations in all the
REPORT OF FOCUS GROUPS RESULTS
61
hospitals of the country to establish specific regulations, belief that immunization is the responsibility of
paediatricians and epidemiologists.
In order to overcome all these barriers for influenza vaccination to healthcare workers should be
provided at work and at no cost, as a component of employee’s health promotion programs.
Attitudinal and organizational enablers for the uptake of vaccines
Some of the enablers for vaccination are the followings: the belief that the main perceived benefit of
vaccination was personal and patient protection against influenza, perception that vaccination protects them
and their families, educational programs and materials, the role of occupational physician as a key person for
promoting vaccination, the existence of a National Seasonal Campaign, self awareness of HCWs for
immunization, the role of the infection control personnel, the door-to-door vaccination and the direct
communication of the infection control personnel with the HCWs that promotes a sense of “caring” for the
staff, the construction of an internet portal in which everyone could log on and fill in questionnaires, the
protection of anonymity, the conduction of surveys in separate groups and the vaccine uptake in the
workplace, the role of mass media, the attitudes of GPs against vaccination, the use of reminders and
vaccination card, the training of the trainers for immunization. In addition, previous personal experience of
a vaccine preventable disease, in particular if complications were experienced, is considered to be cue to
action that includes personal vaccination and vaccine recommendation to the others.
The existence of personal e-mail accounts for HCWs in all the hospitals facilitates the provision of
this material. The campaigns consist an effective way to increase vaccine awareness. On the other hand, the
existence of a National Campaign only for seasonal Influenza and not for other vaccine preventable diseases
that are long-lasting and are also connected with dangerous diseases generate suspicions and cultivates
feelings of insecurity that are related to the relationship between nurses and the market system. As a result
the National Campaigns should be “multiple vaccines” oriented, clear, focused and specific. It should be
noted that the campaigns must incorporate all the hospitals of the country including both seasonal and long
lasting vaccinations. The Infection Control personnel as well as the occupational physician in each hospital
are perceived as the focal points that are accountable for performing HCWs vaccination. The creation of
vaccination offices and teams is beneficial. Moreover the development of a professional health booklet and a
personal health portfolio that keeps records on HCWs’ personal immunizations and informs personnel about
the next immunization appointment has been reported from the majority of the participants. A regular
check of vaccination cards and reminders regarding vaccinations are viewed as reasonable as well as the
development of a mandatory reporting system for vaccinations and side effects.
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62
Specific reference to Influenza vaccination
The findings suggest that the HCWs do not often realise that the influenza virus can be transmitted to
patients and other colleagues by both symptomatic and asymptomatic healthcare staff. As a result the
current policy of voluntary vaccination of healthcare workers is not effective in achieving acceptable
immunisation rates.
1. Attitudinal barriers for the uptake of influenza vaccine
Some of the attitudinal reasons that explain why HCWs do not receive an annual influenza
vaccination are the followings: fear of injections, fear of vaccine side effects and especially influenza-like
symptoms, perceived lack of vaccine efficacy, low personal risk of illness, lack of time to get the vaccine,
lack of risk awareness, lack of knowledge about the benefits of influenza vaccination and the potential
health consequences of influenza illness for them and for patients (holding several misperceptions about
influenza risks), did not often realise that the influenza virus can be transmitted to patients and other
colleagues by both symptomatic and asymptomatic healthcare staff, overall belief that HCWs are well
protected against diseases and flu, HCWs often do not recognise their role in the transmission of influenza
to patients, regarding themselves as low risk for influenza infection, belief that they do not belong to a high-
risk group for contracting the influenza virus (they do not belong to the front line staff).
2. Organizational and institutional barriers for the uptake of influenza vaccine
Some of the organizational and institutional reasons that explain why HCWs do not receive influenza
vaccination are the followings: delayed or lack of availability and distribution of influenza vaccines.
3. Attitudinal and organizational enablers for the uptake of influenza vaccine
Some of the enablers for influenza vaccination are the followings: the belief that the main perceived
benefit of vaccination was personal and patient protection against influenza.
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
DG SANCO Public Health Program 2008 – 2013
Discussion Guide
Work Package
WP 5
Version & Date
v. 0.5 25/07/2012
Document Type
Limited to members of the WP5 and organizers of the focus group
Distribution Status
Limited to members of the WP5 and organizers of the focus group
Editors NHNA
Authors
NHNA
Reviewed by
Prolepsis, KEELPNO
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
Table of Contents
Summary........................................................................................................................................... 4
History changes ................................................................................................................................ 5
1. Introduction .............................................................................................................................. 6
2. The Focus Groups ..................................................................................................................... 7
2.1. Design Principles .................................................................................................................... 7
2.2. Focus Group: Public Health Personnel and Policy Makers ................................................... 7
2.2.1. Description: Discussion Guide ........................................................................................ 7
2.2.2. Program model ....................................................................................................... 10
2.2.3. Focus Group Final Report ............................................................................................. 11
2.3. Focus Group: Administration and Infection Control Personnel ......................................... 13
2.3.1. Description ................................................................................................................... 13
2.3.2. Program model ............................................................................................................. 16
2.3.3. Focus Group Final Report ........................................................................................... 16
2.4. Focus Group: Nurses & Physicians ..................................................................................... 19
2.4.2. Program Model ............................................................................................................. 22
2.4.3. Focus Group Final Report ............................................................................................. 22
3. Timeline ...................................................................................................................................... 25
4. Focus group sessions .................................................................................................................. 26
5. Target group ........................................................................................................................... 26
ANNEX I Guidance for the facilitators ............................................................................................ 27
ANNEX II Checklist for the meeting ................................................................................................ 31
ANNEX III Focus Group Checklist .................................................................................................... 32
ANNEX IV Abbreviations used ........................................................................................................ 33
ANNEX V Consent to Participate in Focus Group Study ................................................................. 34
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
Summary
This document defines the framework for the implementation of the Focus Groups to be
organized in the second semester of 2012 within the remit of the Work Package 5 of the
“HProImmune” Project.
This framework includes setting the objectives, expected outcomes, indicative guidelines for the
local organizers and facilitators.
The framework intends to provide guidance to the focus group facilitators in conducting the
focus groups.
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
History changes
Version Date Author Description / Comments
0.1 28 May 2012 Evangelos Dousis, Maria
Tseroni (NHNA)
First draft version, provide framework
guidelines on the objectives, expected
outcomes, methodology and evaluation for
the organization of the workshops.
0.2 21 June 2012 Evangelos Dousis, Maria
Tseroni (NHNA)
Reviewed by Prolepsis
0.3 28 June 2012 Evangelos Dousis, Maria
Tseroni (NHNA)
Reviewed by Prolepsis
0.4 23 July 2012
Evangelos Dousis, Maria
Tseroni (NHNA)
Reviewed by Prolepsis and KEELPNO
0.5 25 July 2012 Evangelos Dousis, Maria
Tseroni (NHNA)
Reviewed by Prolepsis
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
1. Introduction
The general objective HProImmune Project is to promote vaccination coverage of health care workers in different health care settings by developing a tailored communication tool. With the aim of enhancing European knowledge on HCW immunization, HProImmune will review, summarize and widely disseminate existing information and best practices, explore behaviors and barriers regarding HCW immunization through qualitative analysis. More specifically, HProImmune aims to:
Increase awareness about the most important vaccine preventable diseases which pose a particular risk to EU HCWs
Increase awareness about immunizations among HCWs through a database comprising vaccination specific information from across the EU
Provide new knowledge about vaccination behaviors and barriers among HCWs
Identify best practices for the immunization of health professionals
Work package number 5- EU HCW Barriers to Immunization
Following WP4 findings a series of focus groups will be organized by each country to further
enhance understanding of risk perception behaviors towards vaccination and barriers stopping
HCWs from immunization. Qualitative research through focus groups will contribute to the
development of a toolkit with tailor-made communication strategies for HCWs’ needs.
Since the project targets stakeholders of different levels and settings and barriers to
immunization are diverse, including personal beliefs (cultural) as well as organizational and
operational issues (time, cost, policy), it is necessary to conduct focus groups with different
stakeholders:
1. Front-line health professionals as end users and individuals to be vaccinated,
2. Hospital administrators and infection control personnel as a second level end user,
responsible for planning immunization of larger numbers of HCWs,
3. Public health professionals as providers of scientific advice and policy makers
A pre-developed guide will be used for the focus groups conducted by specialized/trained
professionals.
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
2. The Focus Groups
There will be two Focus Groups for each target HCW group. Wherever necessary more or less
sessions per group can be organized.
1. Public Health Personnel and Policy Makers
2. Administration and Infection Control Personnel
3. Nurses & Physicians
Each Focus Group will cover 4 main areas concerning immunizations:
1. Exploring the issue of Immunizations
2. Knowledge and attitudes about immunizations –concerning patients
3. Knowledge and attitudes about immunizations – concerning themselves
4. Information concerning immunizations at their workplace
The results of all discussions will be transcribed, analyzed and fed into a report, summarizing the
main findings and conclusions of the Focus Groups across all partners.
2.1. Design Principles The design is based on the following three central principles:
Decentralized interactive dialogue: involve variety of knowledge and experience
Central input and synthesis: provoke collaborative thought and reach common
understanding and results
Sharing of ideas, projects and experience: involve all participants in informal and
organized discussions with a wealth and variety of ideas.
Each Focus Group will last approximately 2 hours. For each Focus group a specific discussion
guide has been produced which is shown below.
2.2. Focus Group: Public Health Personnel and Policy Makers
2.2.1. Description: Discussion Guide
I. Introduction and warm up
Outline Focus group objectives: Free contribution of views, audio taping and other discussion
rules. Emphasis will be given to the fact that anonymity and confidentiality will be ensured.
Introductions – moderator and participants
Introduction to the topic of discussion - Vaccine Preventable Diseases, attitudes towards
vaccines among Health care Workers, barriers and enablers
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
Vaccine Preventable Diseases chosen: Influenza, Tuberculosis, Measles, Mumps, Rubella, Meningitis – Meningococcal disease, Varicella, Hepatitis A, Hepatitis B, Pneumococal disease, Tetanus, Diphtheria, Pertussis Vaccines: Seasonal Influenza vaccine, pandemic influenza vaccine, MMR, varicella vaccine,
hepatitis B vaccine, Td, Tdap
The objective during the introductory stage is to create a relaxed atmosphere so as to enable a
fruitful discussion
II. Diagnostic part – – Vaccinations among HCWs
a) Knowledge and attitudes about immunizations – concerning HCW in the hospitals
This process is not pre-scripted but interactive in its nature. The goal is for the participants’
experience to lead the way, therefore eliciting as authentic data as possible.
b) Information concerning the development and implementation of national campaigns
concerning HCW immunizations
The purpose of this part is to gain deep understanding of the way public health personnel and
policy makers handle the issue of HCW immunization -“the real situation”- and the barriers the
development and the implementation of national campaigns for the vaccination of HCWs.
III. Final assessment
The views, needs, benefits and barriers related to immunizations from the perspective of Public
Health Personnel and Policy Makers in 7 different European countries in order to enable the
HProImmune consortium to validate and complement the findings of the literature review and
the online survey. Each Focus Group should therefore, involve approximately 8-10 participants
(including moderator and rapporteur).
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
Table 1: Discussion Guide HProImmune - Public Health Personnel and Policy Makers
Focus Group: Public Health Personnel and Policy Makers
Session Discussion Guide HProImmune Type
1. Introduction and warm up (approx. 10 mins)
Start by explaining the procedure of group discussion to the participants and by asking
them to introduce themselves.
Introduction of the moderator
Explanation of the audio taping as well as explanation of discussion rules – There are no
wrong answers, one should freely express his/her views and suggestions
Introduction to the topic of discussion o Vaccine Preventable Diseases, attitudes towards vaccines among Health care
Workers, barriers and enablers o Vaccine Preventable Diseases chosen: Influenza, Tuberculosis, Measles,
Mumps, Rubella, Meningitis – Meningococcal disease, Varicella, Hepatitis A, Hepatitis B, Pneumococal disease, Tetanus, Diphtheria, Pertussis
o Vaccines: Seasonal Influenza vaccine, pandemic influenza vaccine, MMR, varicella vaccine, hepatitis B vaccine, Td, Tdap
Introduction of the respondents (age, curriculum vitae, profession, work place, activities
or hobbies)
Focus group
2. Diagnostic part – Vaccinations among HCWs (60 mins)
a) Knowledge and attitudes about immunizations – concerning HCW in the hospitals
Do you believe that HCWs are at high risk of exposure to VPDs? For which diseases?
For which categories of HCWs
Which patient groups are more at risk?
Do you consider vaccinations against VPDs as a good way of protecting HCWs and preventing
the spread of diseases or not?
o Needs covered, advantages/disadvantages, further thoughts concerning
effectiveness
Do HCWs get vaccinated for VPDs?
o Explore organizational and attitudinal barriers and enablers
Compulsory, national regulations – for which vaccinations?
Availability or not of information
Effective national campaigns or not
Money constraints
Time constraints
Personal viewpoints concerning vaccinations immunizations
Personal viewpoints concerning effectiveness/side effects of vaccinations
Others…
Focus group
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
b) Information concerning the development and implementation of national campaign
concerning HCW immunizations
Are national or hospital specific regulations concerning vaccinations implemented in this
country?
o If yes, are these regulations implemented?
o Explore reasons (behavioral and attitudinal enablers and barriers)
For which diseases is vaccination compulsory?
What do you think of the particular regulation?
Are national campaigns for the vaccination of HCWs implemented?
o Are these campaigns effective or not?
Explore reasons why they are either effective or not effective (lack of money,
organization, time for proper organization, expertise, knowledge, proper
information, commitment of administrative personnel, policy related barriers)
Which are the barriers that prevent you from developing and implementing a
national campaign for the vaccination of HCWs
o Time
o Money
o Lack of political initiative
o Lack of commitment of public health personnel and policy makers
o Different viewpoints and attitudes of public health personnel and policy makers
concerning HCW’s immunizations
o Lack of compliance of administration and infection control hospitals’ personnel
concerning the implementation of national regulations
o Different viewpoints and attitudes of HCW concerning HCW’s vaccinations
How do you think these barriers could be overcome?
What do you think are the needs of HCWs in relation to vaccination coverage
What do you think would be the elements of a successful campaign for the promotion of
vaccinations among HCWs?
What would be the successful tools for the promotion of vaccinations among HCWs?
e.g. toolkits – informational and educational material, seminars etc
3. Final assessment (approx. 10 mins)
Moderators will conclude asking the participants as following:
“First of all: thank you for your active participation. But before we all leave there are just two
questions I would like to ask…”
I. Is there anything you would like to add – regarding all the topics we had discussed?
II. ……………..(to be spontaneously defined by the moderator)
Focus group
2.2.2. Program model
Table 2: Program
Focus Group: Public Health Personnel and Policy Makers
Sessions Duration
Arrival and registration of participants Participants come to the reception desk, register and receive name tags (coffee-biscuits: where available)
30 minutes
Opening
Session 1: Introduction and warm up
10 minutes
Session 2: Diagnostic part – Vaccinations among HCWs
60 minutes
a) Knowledge and attitudes about immunizations – concerning HCW in the hospitals
b) Information concerning the development and implementation of national campaign
concerning HCW immunizations
Session 3: Final assessment
10 minutes
Closing
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
2.2.3. Focus Group Final Report
Instructions for the report design A report of each Focus Group findings translated in English by each partner until the end of
November 2012.
Summary:
In general, each section should analytically summarise the issues raised about each respective
question for all focus groups conducted with the HCW target groups.
It should explain the context and the “inner meaning” of the points listed, should these not be
self-explanatory. Please try to form groups of answers that are not identical but refer to the
same theme /cluster of answers. They can be either bulleted or in written sentence form or
both. Please provide direct quotations in the summary.
Groups of Public Health Personnel and Policy Makers sharing similar characteristics will appear
in the analysis. Please, indicate these groups wherever they appear and provide arguments in
each section in relation to this, e.g. Public Health Personnel (community nurses).
Quotations:
Please ensure that for each cluster and for each conclusion there is always more than one
quotation referring to its specific item/feature.
Conclusions:
At the end of the analysis report please provide concrete conclusions about the major findings
concerning Vaccinations among HCWs.
Table 3: Focus Group – Analysis Plan
Focus Group: Public Health Personnel and Policy Makers
Content Analysis Type
Cover page
Contents
Abbreviations
Chapter 1 Introduction
Warm-up & life facts of respondents
Please describe the general atmosphere of the participants using quotations or other
interesting facts that could influence or have an impact on the analysis
Summary
(bulleted or
written)
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
Description of the group’s participants (including moderator and rapporteur)
Please provide the results from the screening questionnaires (provide number of participants,
gender and age, educational level, profession and work place). Please don’t provide any
names.
.
Descriptive data
Chapter 2 Diagnostic part – Vaccinations among HCWs
2.1 a. Knowledge and attitudes about immunizations – concerning HCW in the hospitals and the community Describe what participants know and also what knowledge gaps exist indicating the specific
areas in each case connecting these with each group’s characteristics.
Please elicit as authentic data as possible and ensure that for each cluster and for each
conclusion there is always more than one quotation referring to its specific item/feature.
Summary (bulleted or written) – Descriptive data
2.2 b. Information concerning the development and implementation of national campaigns concerning HCW immunizations
Please describe the way public health personnel and policy makers handle the issue of HCW
immunization -“the real situation”- and the barriers faced in the development and the
implementation of national campaigns for the vaccination of HCWs.
Data will be structured according to the by specific factors listed below (using a table or text):
1. Views
2. Needs
3. Benefits
4. Barriers – triggers
5. Enablers
Summarize attitudinal and organizational type of barriers and enablers
Please ensure that for each cluster and for each conclusion there is always more than one
quotation referring to its specific item/feature.
Summary (bulleted or written) – Descriptive data
Chapter 3 Conclusions - Any other comments from the focus group participants
Please ensure that for each cluster and for each conclusion there is always more than one quotation referring to its specific item/feature.
Summary (bulleted or written)
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
2.3. Focus Group: Administration and Infection Control Personnel
2.3.1. Description
I. Introduction and warm up:
Outline Focus group objectives: Free contribution of views, audio taping and other
discussion rules. Ensure confidentiality and anonymity.
Introductions – moderator and participants
Introduction to the topic of discussion - Vaccine Preventable Diseases, attitudes towards
vaccines among Health care Workers, barriers and enablers
Vaccine Preventable Diseases chosen: Influenza, Tuberculosis, Measles, Mumps, Rubella, Meningitis – Meningococcal disease, Varicella, Hepatitis A, Hepatitis B, Pneumococal disease, Tetanus, Diphtheria, Pertussis
Vaccines: Seasonal Influenza vaccine, pandemic influenza vaccine, MMR, varicella vaccine,
hepatitis B vaccine, Td, Tdap
The objective during the introductory stage is to create a relaxed atmosphere so as to
enable a fruitful discussion
II. Diagnostic part – Immunization of HCWs
a) Knowledge and attitudes about vaccinations
b) Knowledge and attitudes about vaccinations among HCWs
c) Information concerning immunizations at their working environment
The purpose of this part is to gain deep understanding of the way administration and
infection control personnel handle the issue of HCW immunization -“the real situation”-
and the barriers and enablers concerning the administrative part of implementing
immunizations for HCW.
III. Final assessment (approx. 10 mins)
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
Table 4: Discussion Guide HProImmune - Administration and Infection Control Personnel
Focus Group: Administration and Infection Control Personnel
Session Discussion Guide HProImmune Type
1. Introduction and warm up (approx. 10 mins)
• Start by explaining the procedure of group discussion to the participants and by asking them
to introduce themselves.
• Introduction of the moderator
• Explanation of the audio taping as well as explanation of discussion rules – There are no
wrong answers, one should freely express his/her views and suggestions
• Introduction to the topic of discussion o Vaccine Preventable Diseases, attitudes towards vaccines among Health care Workers,
barriers and enablers o Vaccine Preventable Diseases chosen: Influenza, Tuberculosis, Measles, Mumps,
Rubella, Meningitis – Meningococcal disease, Varicella, Hepatitis A, Hepatitis B, Pneumococal disease, Tetanus, Diphtheria, Pertussis
o Vaccines: Seasonal Influenza vaccine, pandemic influenza vaccine, MMR, varicella vaccine, hepatitis B vaccine, Td, Tdap
• Introduction of the respondents (age, curriculum vitae, profession, work place)
Focus group
2. Diagnostic part – Immunization of HCWs (approx. 70 mins)
a) Knowledge and attitudes about vaccinations
Which are according to your opinion the most important vaccine preventable diseases? What do most people believe about vaccinations? What do HCWs believe about vaccinations?
o Is there a perception that vaccinations are only for children for example? Do people seek your advice concerning vaccinations?
o When? (childhood vaccinations, pandemics, influenza etc) o How do you communicate? o Do you suggest they get vaccinated or not? o When? (e.g. childhood vaccinations, pandemics, influenza or only for obligatory
vaccinations etc) o Reasons why
Focus group
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
b) Knowledge and attitudes about vaccinations among HCWs
Do you believe your work increases your chances of becoming ill with a VPD?
Do you consider vaccinations as a good way of self-protection / prevention or not?
o Explore reasons why
Do you get vaccinated as a method of prevention and protection because of your high risk
exposure or not?
o Against which diseases are you vaccinated or receive frequent vaccinations (Vaccines/
Diseases - e.g. influenza etc)
o Explore reasons
Practical /organization barriers and enablers – time and cost issues, difficulty of finding
a suitable location, lack of knowledge or adequate information about disease exposure
etc
Attitudinal related barriers and enablers – beliefs about vaccinations, fear of needles,
fear of side effects etc
Other reasons
Focus group
c) Information concerning immunizations – workplace environment
Are there national – regional guidelines/regulations concerning vaccinations among HCWs?
For which diseases (e.g. pandemics, influenza etc)?
Is this regulation implemented? In what way?
Are vaccinations compulsory in your workplace?
For which diseases?
What do you think of the particular regulation?
Is it compulsory for the whole personnel or for specific specialties? Specify
In what way is it communicated to personnel?
Do employees follow the regulation or not
Practical /organization barriers and enablers – time and cost issues, difficulty of finding a
suitable location, lack of knowledge or adequate information about disease exposure etc
Attitudinal related barriers and enablers – beliefs about vaccinations, fear of needles, fear
of side effects, beliefs that these types of workers are not at risk etc
Other reasons
In your opinion what are the barriers that prevent HCWs from becoming vaccinated in your
workplace setting? (The particular question serves also as a summary of what has been
discussed during the conversation)
Summarize attitudinal and organizational type of barriers
o Time
o Money
o Lack of information etc
o Lack of national guidance
o Lack of commitment of personnel concerning compulsory HCW vaccinations
o Lack of educational activities for gaining knowledge e.g. specific seminars, toolkits etc
o Lack of appropriate communication strategies e.g. banners, seminars, brochures etc
How do you think these barriers could be overcome?
If HCWs at your workplace get vaccinated which are the factors that facilitate this process –
which are the enablers
Further thoughts/ ideas concerning “HCW vaccinations enablers” / “appealing ways for
promoting HCW vaccinations”- e.g. toolkits - content of the toolkit, seminars – themes
to be included, other good practices
Focus group
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
3. Final assessment (approx. 10 mins)
Moderators will conclude asking the participants the following:
“First of all: thank you for your active participation. But before we all leave there are just two
questions I would like to ask…”
I. Is there anything you would like to add – regarding all the topics we discussed?
II. ……………..(to be spontaneously defined by the moderator)
Focus group
2.3.2. Program model
Table 5: Program
2.3.3. Focus Group Final Report
A report of each Focus Group findings translated in English by each partner until the end of
November 2012.
Instructions for the report design Summary:
In general, each section should analytically summarise the issues raised about each respective
question for all focus groups conducted with the HCW target groups.
It should explain the context and the “inner meaning” of the points listed, should these not be
self-explanatory. Please try to form groups of answers that are not identical but refer to the
same theme /cluster of answers. They can be either bulleted or in written sentence form or both
in the summary always provide quotations.
Focus Group: Administration and Infection Control Personnel
Sessions Duration
Arrival and registration of participants Participants come to the reception desk, register and receive name tags (coffee-biscuits available)
30 minutes
Opening
Session 1: Introduction and warm up
10 minutes
Session 2: Diagnostic part – Immunization of HCWs 70 minutes
a) Knowledge and attitudes about immunizations
b) Knowledge and attitudes about vaccinations among HCWs
c) Information concerning immunizations in their workplace
Session 3: Final assessment
10 minutes
Closing
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
Groups of Administration and Infection Control Personnel sharing similar characteristics will
appear in the analysis. Please, indicate these groups wherever they appear and provide
arguments in each section in relation to this, e.g. Administration (Nurse Officers).
Quotations:
Please ensure that for each cluster and for each conclusion there is always more than one
quotation referring to its specific item/feature.
Conclusions:
At the end of the analysis report please provide concrete conclusions about the major findings
concerning Immunization of HCWs.
Table 6: Focus Group Report Plan
Focus Group: Administration and Infection Control Personnel
Content Analysis
Type
Cover page
Contents
Abbreviations
Chapter 1 Introduction
Warm-up & life facts of respondents
Please describe the general atmosphere of the participants using quotations or other
interesting facts that could influence or have an impact on the analysis.
Summary
(bulleted or
written)
Description of the group’s participants (including moderator and rapporteur)
Please provide the results from the screening questionnaires (provide number of
participants, gender and age, educational level, profession and work place). Please don’t
provide any names.
Descriptive data
Chapter 2 Diagnostic part – Immunization of HCWs
2.1 a. Knowledge and attitudes about immunizations Describe what participants know and also what knowledge gaps exist indicating the
specific areas in each case connecting these with each group’s characteristics.
Please elicit as authentic data as possible and ensure that for each cluster and for each
conclusion there is always more than one quotation referring to its specific item/feature.
Summary (bulleted or written) – Descriptive data
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
2.2 b. Knowledge and attitudes about vaccinations
Please describe the way administration and infectious control personnel handle the issue
of HCW immunization -“the real situation”- and the barriers faced in the development and
the implementation of national campaigns for the vaccination of HCWs.
Data will be structured according to the by specific factors listed below (using a table or
text):
1. Views
2. Needs
3. Benefits
4. Barriers – triggers
5. Enablers
Summarize attitudinal and organizational type of barriers and enablers
Please ensure that for each cluster and for each conclusion there is always more than one
quotation referring to its specific item/feature.
Summary (bulleted or written) – Descriptive data
2.3. c. Information concerning immunizations at their working environment
Please describe the administration and infection control personnel handle the issue of
HCW immunization - “the real situation” - and the barriers concerning the administrative
part of implementing immunizations for HCW.
Data will be structured in the specific areas listed below (using a table or text):
1. Views
2. Needs
3. Benefits
4. Barriers - triggers
5. Enablers
Summarize attitudinal and organizational type of barriers and enablers
Please ensure that for each cluster and for each conclusion there is always more than one
quotation refers to its specific item/feature.
Summary (bulleted or written) – Descriptive data
Chapter 3 Conclusions - Any other comments of focus group participants
Please ensure that for each cluster and for each conclusion there is always more than one
quotation refers to its specific item/feature.
Summary
(bulleted or
written)
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
2.4. Focus Group: Nurses & Physicians
2.4.1. Description
I. Introduction and warm up:
Outline Focus group objectives: Free contribution of views, audio taping and other
discussion rules. Ensure that confidentiality and anonymity are ensured.
Introductions – moderator and participants
Introduction to the topic of discussion - Vaccine Preventable Diseases, attitudes towards
vaccines among Health care Workers, barriers and enablers
Vaccine Preventable Diseases chosen: Influenza, Tuberculosis, Measles, Mumps, Rubella, Meningitis – Meningococcal disease, Varicella, Hepatitis A, Hepatitis B, Pneumococal disease, Tetanus, Diphtheria, Pertussis
Vaccines: Seasonal Influenza vaccine, pandemic influenza vaccine, MMR, varicella vaccine,
hepatitis B vaccine, Td, Tdap
The objective during the introductory stage is to create a relaxed atmosphere so as to
enable a fruitful discussion
II. Diagnostic part – Vaccinations of HCWs
a) Vaccinations among HCWs – exploring the issue (5-10 mins – to be kept short)
b) Knowledge and attitudes about vaccinations – personal views
c) Knowledge and attitudes about vaccinations among HCWs
d) Information concerning immunizations at their workplace
The purpose of this part is to gain deep understanding of the way administration and
infection control personnel handle the issue of HCW immunization - “the real situation” -
and the barriers concerning the administrative part of implementing immunizations for
HCW.
III. Final assessment
The purpose of this part is to gain deep understanding of the way physicians handle the
issue of their own immunization - “the real situation” - as well as the beliefs that they
hold about that and inevitably affect their attitude .
Moreover, emphasis is given on whether compulsory immunizations are provided at
their working place, in which cases as well as their attitudes and beliefs towards them.
The particular investigation will enhance a deeper understanding concerning the triggers
and barriers of their personal immunization.
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
Table 7: Discussion Guide HProImmune - Nurses & Physicians
Focus Group: - Nurses & Physicians
Session Discussion Guide HProImmune Type
1. Introduction and warm up (approx. 10 mins)
• Start by explaining the procedure of group discussion to the participants and by asking
them to introduce themselves.
• Introduction of the moderator
• Explanation of the audio taping as well as explanation of discussion rules – There are no
wrong answers, one should freely express his/her views and suggestions
• Introduction to the topic of discussion o Vaccine Preventable Diseases, attitudes towards vaccines among Health care
Workers, barriers and enablers o Vaccine Preventable Diseases chosen: Influenza, Tuberculosis, Measles, Mumps,
Rubella, Meningitis – Meningococcal disease, Varicella, Hepatitis A, Hepatitis B, Pneumococal disease, Tetanus, Diphtheria, Pertussis
o Vaccines: Seasonal Influenza vaccine, pandemic influenza vaccine, MMR, varicella vaccine, hepatitis B vaccine, Td, Tdap
• Introduction of the respondents (age, curriculum vitae, profession, work place, activities
or hobbies)
Focus group
2. Diagnostic part – Immunization of HCWs (approx. 70 mins)
a) Vaccinations among HCWs – exploring the issue (5-10 mins – to be kept short)
“Vaccinations…” or “…as an expert what would you say about vaccinations…”
Observe spontaneous reactions
Respondents will be encouraged to discuss cases, share opinions, images, memories etc by
using adjectives, words, situations related to immunizations
In this way, we will explore a series of questions to be followed by relevant prompts to clarify the issue
This process is not pre-scripted but interactive in its nature. The goal is for the participants’ experience
to lead the way, therefore eliciting as authentic data as possible.
Record the topic list on a chart or white board for reference and give constant prompts to make
certain that this is a complete list of potentially relevant topics.
Focus group
b) Knowledge and attitudes about vaccinations – personal views
Which are according to your opinion the most important vaccine preventable diseases? What do most people believe about vaccinations? What do HCWs believe about vaccinations?
o Is there a perception that vaccinations are only for children for example? o Do you feel confident in providing advice about vaccinations? o What sort of advice is requested?
Do people seek your advice concerning vaccinations? o When? (childhood vaccinations, pandemics, influenza etc) o How do you communicate? o Do you suggest they are vaccinated or not? o When? (e.g. childhood vaccinations, pandemics, influenza or only for obligatory
vaccinations etc) o Reasons why
Focus group
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
c) Knowledge and attitudes about vaccinations among HCWs
Do you believe your work increases your chances of becoming ill or transmitted with a VPD?
Do you consider vaccinations as a good way of self protection / prevention or not?
Explore reasons why
Do you get vaccinated as a method of prevention and protection because of your high risk
exposure or not?
Against which diseases are you vaccinated or receive frequent vaccinations (Vaccines/ Diseases -
e.g. influenza etc)
Explore reasons
o Practical /organization barriers and enablers – time and cost issues, difficulty of finding a
suitable location, lack of knowledge or adequate information about disease exposure etc
o Attitudinal related barriers and enablers – beliefs about vaccinations, fear of needles,
fear of side effects etc
o Other reasons
Focus group
d) Information concerning immunizations at their working environment
Are there national – regional guidelines/regulations concerning vaccinations among HCWs?
For which diseases (e.g. pandemics, influenza etc)?
Is this regulation implemented? In what way?
Are vaccinations compulsory in your workplace?
For which diseases?
What do you think of the particular regulation?
Is it compulsory for the whole personnel or for specific specialties?
In what way is it communicated to personnel?
Do employees follow the regulation or not
Practical /organization barriers and enablers – time and cost issues, difficulty of finding a
suitable location, lack of knowledge or adequate information about disease exposure etc
Attitudinal related barriers and enablers – beliefs about vaccinations, fear of needles, fear of
side effects, beliefs that these types of workers are not at risk etc
Other reasons
In your opinion what are the barriers that prevent HCWs from becoming vaccinated in your
workplace setting? (The particular question serves also as a summary of what has been discussed
during the conversation)
Summarize attitudinal and organizational type of barriers
o Time, Money, Lack of information etc
o Lack of national guidance
o Lack of commitment of personnel concerning compulsory HCW vaccinations
o Lack of educational activities for gaining knowledge e.g. specific seminars, toolkits etc
o Lack of appropriate communication strategies e.g. banners, seminars, brochures etc
How do you think these barriers could be overcome?
Further thoughts/ ideas concerning “HCW vaccinations enablers” / “appealing ways for
promoting HCW vaccinations”- e.g. toolkits - content of the toolkit, seminars – themes to
be included, other good practices
If HCWs at your workplace get vaccinated which are the factors that facilitate this process –
which are the enablers
The purpose of this part is to gain deep understanding of the way Nurses and Doctors handle the issue
of HCW immunization -“the real situation”- and the barriers and enablers concerning the
administrative part of implementing immunizations for HCW.
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
3. Final assessment (approx. 10 mins)
Moderators will conclude asking the participants as following:
“First of all: thank you for your active participation. But before we all leave there are just two
questions I would like to ask…”
I. Is there anything you would like to add – regarding all the topics we had discussed?
II. ……………..(to be spontaneously defined by the moderator)
The purpose of this part is to gain deep understanding of the way nurses and physicians handle the
issue of their own immunization -“the real situation”- as well as the beliefs that they hold about that
and inevitably affect their attitude .
Moreover, emphasis is given on whether compulsory immunizations are provided at their workplace,
in which cases as well as their attitudes and beliefs towards them. The particular investigation will
enhance a deeper understanding concerning the triggers and barriers of their personal immunization.
Focus group
2.4.2. Program Model
Table 8: Program
2.4.3. Focus Group Final Report
A report of each Focus Group findings translated in English by each partner until the end of
November 2012.
Instructions for the report design Summary:
In general, each section should analytically summarise the issues raised about each respective
question for all focus groups conducted with the HCW target groups.
Focus Group: Nurses & Physicians
Sessions Duration
Arrival and registration of participants Participants come to the reception desk, register and receive name tags (coffee-biscuits: provided where available)
30 minutes
Opening
Session 1: Introduction and warm up
10 minutes
Session 2: Diagnostic part – Immunization of HCWs 70 minutes
a) Vaccinations among HCWs – exploring the issue (5-10 mins – to be kept short)
b) Knowledge and attitudes about vaccinations – personal views c) Knowledge and attitudes about vaccinations among HCWs d) Information concerning immunizations at their working environment
60 minutes
Session 3: Final assessment
10 minutes
Closing
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
It should explain the context and the “inner meaning” of the points listed, should these not be
self-explanatory. Please try to form groups of answers that are not identical but refer to the
same theme /cluster of answers. They can be either bulleted or in written sentence form or both
in the summary always provide quotations.
Groups of Nurses & Physicians sharing similar characteristics will appear in the analysis. Please,
indicate these groups wherever they appear and provide arguments in each section in relation to
this, e.g. Nurses (surgical ward nurses).
Quotations:
Please ensure that for each cluster and for each conclusion there is always more than one
quotation refers to its specific item/feature.
Conclusions:
At the end of the analysis report please provide concrete conclusions about the major findings
concerning Vaccinations of HCWs.
Table 9: Focus Group Report Plan
Focus Group: Nurses & Physicians
Content Analysis
Type
Cover page
Contents
Abbreviations
Chapter 1 Introduction
Warm-up & life facts of respondents
Please describe the general atmosphere of the participants using quotations or other
interesting facts that could influence or have an impact on the analysis.
Summary
(bulleted or
written)
Description of the group’s participants (including moderator and rapporteur)
Please provide the results from the screening questionnaires (provide number of
participants, gender and age, educational level, profession and work place). Please don’t
provide any names.
Descriptive data
Chapter 2 Diagnostic part – Vaccinations of HCWs
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
2.1 a. Vaccinations among HCWs – exploring the issue Describe the spontaneous reactions and the discussion of cases, sharing opinions, images,
memories etc by using adjectives, words, situations related to immunizations.
Please elicit as authentic data as possible and ensure that for each cluster and for each
conclusion there is always more than one quotation referring to its specific item/feature.
Summary (bulleted or written) – Descriptive data
2.2 b. Knowledge and attitudes about vaccinations – personal views
Please describe the way nurses and doctors handle the issue of HCW immunization -“the
real situation”- and the barriers faced in the development and the implementation of
national campaigns for the vaccination of HCWs.
Data will be structured according to the by specific factors listed below (using a table or
text):
1. Views
2. Needs
3. Benefits
4. Barriers – triggers
5. Enablers
Summarize attitudinal and organizational type of barriers and enablers
Please ensure that for each cluster and for each conclusion there is always more than one
quotation referring to its specific item/feature.
Summary (bulleted or written) – Descriptive data
2.3. c. Information concerning immunizations at their working environment
Please describe how nurses and physicians handle the issue of HCW immunization - “the
real situation” - and the barriers concerning the administrative part of implementing
immunizations for HCW.
Data will be structured in the specific areas listed below (using a table or text):
1. Views
2. Needs
3. Benefits
4. Barriers – triggers
5. Enablers
Summarize attitudinal and organizational type of barriers and enablers
Please ensure that for each cluster and for each conclusion there is always more than one
quotation refers to its specific item/feature.
Chapter 3 Conclusions - Any other comments of focus group participants
Please ensure that for each cluster and for each conclusion there is always more than one
quotation refers to its specific item/feature.
Summary
(bulleted or
written)
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
3. Timeline
Date
Country
Focus Group
Partner
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
4. Focus group sessions
As illustrated in above tables there will two focus groups with three sessions each. Each focus
group will have a moderator and a rapporteur.
The moderator of each focus group will need to ensure maximum participation, target and result
orientation. One of the participants of the focus group will be asked to act as the rapporteur for
the group. The main role of the rapporteur will be to keep track and take notes of the main
issues discussed in the focus group and report back the outcomes of the discussion. Should there
be no volunteer for the role of rapporteur, then the facilitator will have to take up this additional
responsibility.
The role of the facilitator is crucial in conducting the focus groups effectively especially in terms
of providing clear explanations of the purpose of the group, helping people feel at ease, and
facilitating interaction between group members. To this end, it is important that the facilitators
have good interpersonal skills in order to promote participants’ trust in the facilitator and
increase the likelihood of open and interactive dialogue.
5. Target group
Each Focus Group should aim to ensure an active participation of circa 8-10 participants
representing each of the three groups of HCWs identified for this project. The organizers of the
Focus Group shall aim at a balanced representation of the three groups.
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
ANNEX I Guidance for the facilitators
1. Confidentiality
It is imperative that no one but the organizers (and the participants themselves) know the names
of participants. Furthermore, people other than the members of the Consortium should not have
access to the responses from individual participants, whether accidental or intentional.
Do not write the names of respondents on the form for taking interview notes. If necessary use a
unique code assigned to the respondent to protect confidentiality.
2. Building Rapport
Participants as experts
Individuals are being invited to participate in focus groups because they are viewed as possessing
important knowledge about particular experiences, needs, or perspectives that we hope to learn
more about as a result of the needs assessment. Let participants know that you are there to
learn from them. Expressing this to participants helps to establish a respectful appreciation for
valuable contributions that they will make to the needs assessment.
Your role as facilitator/moderator
It is important to present yourself as a facilitator/moderator rather than a friend. You will need
to let participants know that you are part of a team that is conducting a study for a community
needs assessment. This formality communicates to participants that their participation is
important and contributes to the community.
Balancing rapport and professionalism
Part of your role is to achieve a balance between building rapport with participants and
conveying an appropriate level of professionalism. Your role during focus groups is not that of a
good conversationalist or a friend who provides feedback, but a professional. If you are too
casual, participants may not see you as someone who is prepared to take what they have to say
seriously. However, if you are too formal, participants may feel intimidated by you and may not
be as willing to reveal information. Strive to achieve a balance between being formal and casual
during your focus groups.
Recognizing and appreciating participants for their time and contributions
This is one of the most important things you can do to help create rapport. Remember to thank
participants for their time and participation. Let them know that the information they have
shared is valuable for this project.
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
3. Listening skills
Listen carefully to participants
Active listening allows you to probe effectively and at appropriate points during the focus group.
Active listening involves not only hearing what someone is saying, but also noticing body posture
and facial gestures (i.e., any changes in nonverbal behavior) that might provide cues as to the
appropriate or necessary ways to engage participants.
Show participants you are listening
Show participants that you are listening to what they are saying. Signs that you are paying
attention may include leaning forward slightly, looking directly at participants while they are
speaking, or nodding at appropriate times. Such behaviors not only indicate that you, as the
facilitator, are more engaged, but also will help maintain the engagement of participants,
themselves. Looking away, yawning, or frequently checking your watch will most likely make
participants feel that you are not listening. If participants suspect that you are not listening to
them with great care, they may take their role of sharing expert knowledge less seriously and,
therefore, may not elaborate or provide much detail with their answers.
The importance of neutrality during the interview
While showing participants that you are actively listening and interested in what they are
sharing, you will also want to remain as neutral or impartial as possible, even if you have a strong
opinion about something. Use phrases such as “Thank you. That is helpful.” Comments such as “I
can’t believe it!” or “You really think that?!” are not appropriate remarks for a facilitator to
make, because they infer your opinion and impose judgment on the participant, which will shut
down discussion.
4 Qualities of an Effective Focus Group Facilitator
Roles and Responsibilities: Keep participants focused, engaged, attentive and interested
Monitor time and use limited time effectively
Use prompts and probes to stimulate discussion
Use the focus group guide effectively to ensure all topics are covered
Politely and diplomatically enforce ground rules: o Make sure everyone participates and at a level that is comfortable o Limit side conversations o Encourage one person to speak at a time
Be prepared to explain or restate questions
Diffuse and pre-empt arguments
After the focus group, work with the note taker to complete the Debrief Discussion Tool immediately after each focus group. To facilitate the debriefing discussion, review the notes of the discussion, discussing areas that seemed particularly important or salient given your knowledge of the research questions. Capture these insights using the Debrief Discussion Tool.
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
[Need to determine who will take responsibility for these notes, as well as the consent forms, Debriefing Discussion Tool and tapes of the focus group discussion.]
Effective Facilitators:
Have good listening skills
Have good observation skills
Have good speaking skills
Can foster open and honest dialogue among diverse groups and individuals
Can remain impartial (i.e., do not give her/his opinions about topics, because
this can influence what people say)
Can encourage participation when someone is reluctant to speak up
Can manage participants who dominate the conversation
Are sensitive to gender and cultural issues
Are sensitive to differences in power among and within groups
1. Roles and Responsibilities of Note Takers
Bring the following materials for the focus group:
Materials to record the focus group, including writing utensils (more than one, in case a pencil breaks or a pen runs out of ink) and a lot of paper
Bring a flip chart as well as markers of different colors for recording information (as needed) on a flip chart or dry erase board. NOTE: if a dry erase board will be used in place of a flip chart, be sure that dry erase markers are available or that you bring this type of marker.
Tape for affixing flip chart pages to the wall, as needed.
Recording equipment: a tape recorder, extension cord, extra tapes, and extra batteries
Ensure that ground rules for the focus group are written clearly and neatly on a flip chart (it may be helpful to do this beforehand)
Assist the facilitator in arranging the room (e.g., seating, flip chart stand and paper, placement of the ground rules, etc.)
Record major themes, ideas, comments and observations regarding group dynamics in hand-written notes
Conduct a debriefing discussion with the focus group facilitator immediately after each focus group. To facilitate the debriefing discussion, review your notes with the focus group facilitator. Capture any new insights that emerged as a result of this discussion with the facilitator.
Do not throw away any papers with notes of the focus group discussion. These will be stored with other data collected through the needs assessment.
[Need to determine who will take responsibility for these notes, as well as the consent forms, Debriefing Discussion Tool and tapes of the focus group discussion.]
Effective Note Takers:
Have good listening skills
Have good observation skills
Have good writing skills
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
Are able to take notes that are comprehensive but not word-for-word
Use the note taking form provided
Act as an observer, not as a participant
Can remain impartial (i.e., do not give her/his opinions about topics, because this can influence what people say)
2. Time management
Managing time during the interview
Individuals love to talk about their experiences and may have a tendency to go on and on about
them. Here is where your skills as an interviewer are put to the test. As the interviewer, your job
is to structure the interview in such a way that you elicit a complete response to questions,
probing insightfully so that you get the level of detail you need in order to the issues adequately.
Keep the interview moving
It is also your job to politely move the interview forward when what the respondent is sharing is
less useful given your topics of discussion. Other times, you may want to acknowledge that your
time together is waning and there are some other aspects of their work and experience that you
want to be sure you have time to learn about and explore, and, for this reason, you are going to
move on.
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
ANNEX II Checklist for the meeting
Remember to bring the following:
Two writing utensils (in case the lead in a pencil breaks/ a pen runs out of ink)
A notepad with sufficient paper for taking notes during the entire focus group
A flip chart
Dry Erase and/or regular markers of different colors
Name tags or badges
Tape for affixing flip chart pages to the wall, as needed.
Focus group guide
Note taking form
For further information regarding guidance and tips for the facilitators/moderators please
consult the following link: http://www.omni.org/docs/FocusGroupToolkit.pdf
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
ANNEX III Focus Group Checklist
Remember to do the following…
Check with (X)
To do
Become very familiar with the primary research objectives of the study
Become very familiar with the focus group guide
Review this checklist
Arrive at the focus group location a few minutes before participants to organize the room and your materials
Welcome focus group participants, inviting them to get something to eat
Explain, in a general and brief way, the purpose of the focus group and how information collected during focus groups will be used and toward what goal
Introduce yourself, the note taker and other observer (if present)
Explain participants’ rights and what participating in the focus group will entail
Remind participants of the duration of the focus group, emphasizing the importance of their participation during the entire discussion
Let people know where the closest restroom facilities are located
Obtain written consent to participate and have the focus group recorded
At the end of the focus group, give the participants the contact information of [whom] should they have any questions
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
ANNEX IV Abbreviations used
Abbreviation* Partner Country National Institute of Infectious Diseases Romania
Nofer Institute of Occupational Medicine Poland
Mokymų Tyrimų ir Vystymo Centras
Lithuania
Istituto Superiore Di Sanità
Italy
Cyprus University of Technology
Cyprus
Technische Universität Dresden
Germany
National Hellenic Nurses Association (NHNA)
Greece
Hellenic Center for Disease Control and Prevention (KEELPNO)
Greece
Occupational Health (OCH) WHO/EURO Centre for Environment and Health
Germany
Health Protection Agency, Centre for Infectious Diseases UK
*: to provide where needed
HProImmune: Focus Groups Discussion Guide
© Copyright 2012, the Members of the HProImmune Consortium
ANNEX V Consent to Participate in Focus Group Study
The purpose of the group discussion and the nature of the questions have been explained to me. I consent to take part in a focus group about my experiences concerning vaccinations among Health Care Workers. I also consent to be tape -recorded during this focus group discussion. My participation is voluntary. I understand that I am free to leave the group at any time. I have the right to withdraw from the discussion at any time. None of my experiences or thoughts will be made public or shared with anyone unless all identifying information is removed first. The information that I provide during the focus group will be grouped with answers from other people so that I cannot be identified.
Please Print Your Name Date
Please Print Your Name Date
Please Print Your Name Date
Please Print Your Name Date
Please Print Your Name Date
Please Print Your Name Date
Please Print Your Name Date
Please Print Your Name Date
Please Print Your Name Date
Part 1: Demographics 1/14 What is your gender?
1. Male 2. Female
2/14 What is your age?
1. 18 to 24 years 2. 25 to 34 years 3. 35 to 44 years 4. 45 to 54 years 5. 55 to 64 years 6. 65 years and over
3/14 Country of employment 4/14 What is the highest degree or level of school you have completed?(If currently enrolled,
mark the previous grade or highest degree received)
1. Primary school 2. Secondary school 3. Vocational training (technical schools, apprenticeship or other equivalent) 4. Academic degree 5. Postgraduate degree
5/14 What is your current profession
Medical Doctor
1. Pediatric specialty or subspecialty 2. Surgical specialty or subspecialty 3. Internal medicine specialty or subspecialty 4. General Practice, family medicine or equivalent 5. Laboratory 6. Other
Nurse
1. Hospital nurse 2. Emergency Department nurse (A&E) 3. Infection control nurse 4. Public health nurse 5. Midwife or maternal health nurse
6. Child health or school health nurse 7. Primary health care nurse 8. Nurse in other settings (nursing home, outpatient clinic) 9. Other
Allied Health Professionals in contact with patients
1. Pharmacist 2. Dieticians 3. Physical, Occupational, Respiratory Therapists 4. Dental Hygienists 5. Social workers 6. Psychologists 7. Hospital epidemiologists 8. Ambulance personnel 9. Laboratory Technicians 10. Assistants / Aides (e.g. home health aides, orderlies, attendants) 11. Administrative health care service personnel 12. Nonclinical Support personnel of health care facilities (Food services, maintenance,
housekeeping/other technical support, janitors) 13. Other
6/14 In which setting do you work?
1. Public regional/community Hospital 2. Private regional/community Hospital 3. Public tertiary/university Hospital 4. Specialty clinics (i.e. obstetrics/gynecology, psychiatry etc) 5. Long term care facilities (i.e. nursing homes, chronic care facilities etc.) 6. Primary Health Care Center(including outpatient or ambulatory clinic, maternal
health care center, Child health care center, School health care center) 7. Private practice 8. Public Health Institute or other governmental organization 9. Academia 10. Industry 11. Other setting
7/14 Years of experience in current profession
1. Less than 2 2. 2 to 5 3. 6 to 10 4. More than 10
Part 2: Vaccination behavior
8/14 Which of the following statements do you feel that best reflects your personal view about vaccines:
1. I believe vaccines are important for reducing or eliminating serious diseases 2. I believe that vaccines are useful in particular settings for example in the developing
world 3. Not sure 4. I believe in challenging natural immunity by contracting the disease rather than
getting vaccinated 5. I don't believe in vaccinations, I believe that they do more harm than good
9/14 Which of the following diseases do you believe that Health Care Workers are more at risk of contracting due to the nature of their work?(you can choose more than one)
1. Influenza (flu) 2. Tuberculosis 3. Measles 4. Mumps 5. Rubella (German measles) 6. Meningitis 7. Varicella (chickenpox) 8. Hepatitis A 9. Hepatitis B 10. Pneumococcal disease 11. Tetanus 12. Diphtheria 13. Pertussis (whooping cough) 14. Other
10/14 Which of the following diseases do you believe that Health Care Workers are more at risk of transmitting to patients and family?(you can choose more than one)
1. Influenza (flu) 2. Tuberculosis 3. Measles 4. Mumps 5. Rubella (German measles) 6. Meningitis - Meningococcal disease 7. Varicella (chickenpox) 8. Hepatitis A 9. Hepatitis B 10. Pneumococcal disease 11. Tetanus 12. Diphtheria 13. Pertussis (whooping cough)
14. Other 11/14 Are you required by your hospital/organization to prove immunity against any of the following Vaccine Preventable Disease(s) before you begin to work?
o Yes (you can choose more than one): 1. Measles 2. Mumps 3. Rubella (German measles) 4. Varicella (chickenpox) 5. Hepatitis B 6. Pertussis (whooping cough) 7. Other
o No
12/14 Are you required by your employer to receive the seasonal influenza vaccine every year?
1. Yes 2. No
13/14 If you have or haven't received any of the following vaccines in the last 10 years please indicate your reason(s) for doing so by marking the appropriate box(es)(you may choose more than one)
1. Seasonal Influenza (flu) vaccine
2. Pandemic influenza (swine flu) vaccine
3. MMR (mumps-measles-rubella vaccine)
4. Varicella (chickenpox) vaccine
5. Hepatitis B vaccine
6. Td (adult tetanus vaccine) or Tdap (adult tetanus, diphtheria and pertussis vaccine)
o I have received
1. I was afraid of contracting the disease 2. I believe I am at risk of acquiring the disease 3. I believe in the protection that vaccines offer 4. I do not wish to transmit any disease to the patients I come into contact with 5. It was available in my work place 6. It was offered free of charge 7. I was required by my employer to be vaccinated 8. I felt pressured by my colleagues/friends/familly
9. Any other reason (please specify)
o I haven't received
1. I have contracted this disease in the past 2. I have already received this vaccination in the past 3. I have experienced side effects from a previous vaccine dose 4. My religious beliefs are against vaccinations 5. I believe in challenging natural immunity by contracting the disease rather than
getting vaccinated 6. I don't believe I am at risk for any of those diseases 7. I am concerned about vaccine side effects 8. I am concerned about becoming ill after receiving the vaccine 9. I am concerned that the vaccine will not work 10. I am afraid of needles 11. I am skeptical about the long-term health effects of vaccines 12. I have to go out of my way to get the vaccine 13. I don't have time to get a vaccine 14. My employer/insurance does not cover vaccination costs 15. I don't know where to obtain a vaccination 16. Any other reason (please specify)
o I don't remember
14/14 Do you think that it should be mandatory for HCWs who come in regular contact with patients to be vaccinated against VPDs?
1. Strongly agree 2. Agree 3. Not sure 4. Disagree 5. Strongly disagree
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