IMMUNIZATION BARRIERS AND ENABLERS AMONG HEALTH … · Identify best practices for the immunization of health professionals ... Croatia 2 0,04 Netherlands 2 0,04 Slovakia 2 0,04 Argentina

1

IMMUNIZATION BARRIERS AND

ENABLERS AMONG HEALTH CARE

PROFESSIONALS: ANALYSIS OF

FINDINGS

2

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

3

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.

4

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

5

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

6

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.

7

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

8

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

9

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).

10

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)

11

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).

12

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

13

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.

14

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.

15

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

16

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

17

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.

18

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

19

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).

20

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.

21

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

22

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)

23

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).

24

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

25

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

26

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)

27

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)

28

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.

29

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

30

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).

31

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)

32

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

33

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).

34

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)

35

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)

36

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.

37

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)

38

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)

39

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%).

40

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


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)


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


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


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)


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


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


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.


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


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


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.


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.


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


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


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


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


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


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


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


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.


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


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


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


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.


Public Health Personnel and Policy Makers shared similar views regarding immunization,

with nurses and physicians.

Germany


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


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.


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.


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”


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”


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


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


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.


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


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


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”


“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


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….”.


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…


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,


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


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”


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


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…..”


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


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…..”


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.


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


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


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”


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.


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


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)


(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


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


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


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


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


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


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


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


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


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,


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


“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 –


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


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.”


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


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


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.


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


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


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


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.


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





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



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.



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)


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)




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.



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.


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



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).



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)


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



b) Information concerning the development and implementation of national campaign


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


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


b) Information concerning the development and implementation of national campaign


Session 3: Final assessment

10 minutes

Closing



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


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 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




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)



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.




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,


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)



Table 4: Discussion Guide HProImmune - Administration and Infection Control Personnel

Focus Group: Administration and Infection Control Personnel



• 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


• 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


• 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




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?


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


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




Moderators will conclude asking the participants the following:



I. Is there anything you would like to add – regarding all the topics we discussed?


Focus group

2.3.2. Program model

Table 5: Program


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:





same theme /cluster of answers. They can be either bulleted or in written sentence form or both

in the summary always provide quotations.


Sessions Duration

Arrival and registration of participants Participants come to the reception desk, register and receive name tags (coffee-biscuits available)

30 minutes

Opening


10 minutes

Session 2: Diagnostic part – Immunization of HCWs 70 minutes

a) Knowledge and attitudes about immunizations


c) Information concerning immunizations in their workplace


10 minutes

Closing



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:



Conclusions:


concerning Immunization of HCWs.

Table 6: Focus Group Report Plan


Content Analysis

Type

Cover page

Contents

Abbreviations




interesting facts that could influence or have an impact on the analysis.

Summary

(bulleted or

written)


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.






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


5. Enablers





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



quotation refers to its specific item/feature.


Chapter 3 Conclusions - Any other comments of focus group participants



Summary

(bulleted or

written)



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.




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,


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.



Table 7: Discussion Guide HProImmune - Nurses & Physicians

Focus Group: - Nurses & Physicians



• 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


• 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


• Introduction of the respondents (age, curriculum vitae, profession, work place, activities

or hobbies)

Focus group

2. Diagnostic part – Immunization of HCWs (approx. 70 mins)


“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



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


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?


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


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


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.




Moderators will conclude asking the participants as following:



I. Is there anything you would like to add – regarding all the topics we had discussed?


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


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:



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


10 minutes

Session 2: Diagnostic part – Immunization of HCWs 70 minutes


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


10 minutes

Closing





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:



Conclusions:


concerning Vaccinations of HCWs.

Table 9: Focus Group Report Plan

Focus Group: Nurses & Physicians

Content Analysis

Type

Cover page

Contents

Abbreviations




interesting facts that could influence or have an impact on the analysis.

Summary

(bulleted or

written)


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



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.




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


5. Enablers





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


5. Enablers




Chapter 3 Conclusions - Any other comments of focus group participants



Summary

(bulleted or

written)



3. Timeline

Date

Country

Focus Group

Partner



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.



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.



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.



[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



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.



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

http://www.omni.org/docs/FocusGroupToolkit.pdf



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



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



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









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

Submit survey Your survey responses have been submitted! Thank you for taking part in our survey. Your responses have been securely submitted to us for analysis. If you would like to receive the HproImmune newsletter please provide us with your email:

Documents

IMMUNIZATION BARRIERS AND ENABLERS AMONG HEALTH … · Identify best practices for the immunization of health professionals ... Croatia 2 0,04 Netherlands 2 0,04 Slovakia 2 0,04 Argentina