Increasing annual influenza vaccinations among healthcare workers in Rhode Island: a social marketing approach.

Approximately 226,000 excess hospitalizations and 36,000 deaths occur each year in the US due to influenza-related illness.1 In addition to their own risk of disease, unvaccinated healthcare workers can transmit influenza virus unknowingly to high-risk patients prior to the onset of symptoms.1 Annual influenza vaccinations for healthcare workers can prevent workers from becoming ill and may decrease morbidity and mortality among patients at high risk for complications. For the past 20 years, the Centers for Disease Control and Prevention’s (CDC)’s Advisory Committee on Immunization Practices1 has recommended healthcare worker annual influenza vaccination to protect both healthcare workers and patients from infection. 1 Despite repeated urgings, uptake of influenza vaccination remains low.2 In 2004 and 2006, vaccination rates among healthcare workers were 42% nationally3 and 33.9% among nursing home healthcare workers in Rhode Island.4 Studies show that education alone has little effect. 5 A social marketing strategy6 combined with “stages of change” theory may facilitate influenza immunization among healthcare workers by reducing the barriers and increasing the benefits of behavior change. John and Cheney (2007) used data from 74 participants in eight focus groups to assess the psychographics of healthcare workers (age 30+ years) who did not receive influenza vaccine in 2006-2007.7 The researchers found that most respondents perceived influenza as a “mild” disease and demonstrate a “low level of concern,” despite the fact that 81% had one of the “highrisk” characteristics or health conditions for which CDC indicates high priority for annual influenza vaccination and 23% worked in a healthcare setting or with children. Nearly two-thirds of these healthcare workers either never had a flu shot or had not had one for more than 10 years! Onethird of all participants believed the vaccine “made them sick.” Another one-third distrusted the vaccine’s value or “safety.” The final third were not resistant, but cited some “inconvenience” as a barrier. The authors identified three audience segments: “Plans to Get,” “Needs More Information,” and “Makes You Sick.” They proposed new messages to promote increased participation in the first two segments, and asserted that no special efforts should be directed to members of the “makes you sick” group, who would probably not get a shot “until the price of resistance becomes too high.” The authors argued that strategic use of the marketing mix (product, price, place, promotion)—usually available to social marketers— was severely limited in this case, since it is impossible to change the physical nature of the flu vaccine product, except, perhaps, for the injection and nasal methods of administration. The Stages of Change theory8, 9 regards behavior change as a process, rather than an event. By understanding the stage in which each subject resides (precontemplation, c o n t e m p l a t i o n , preparation, action, maintenance and relapse), practitioners can design interventions tailored to the subject’s status in the process. Doing so, rather than using the “one size fits all approach,” improves movement to the target behavior. Our project combines the social marketing approach with stages of change theory to explore ways to increase the uptake of influenza vaccine among healthcare workers. Social marketing helps to identify past and present behavior of healthcare workers and the underlying dimensions of their “decisional balance,” “self-efficacy,” and intentions toward annual vaccine use. These characterizations can fit into stages of change theory to develop strategies for increasing vaccination rates among healthcare workers.