Exploring Strategies to Promote Influenza Vaccination of Children with Medical Comorbidities: The Perceptions and Practices of Hospital Healthcare Workers

Physicians have been described as a trusted source of information whom parents rely upon to initiate vaccine conversations. It has been reported that a recommendation from a hospital-based physician is a stronger predictor of influenza vaccination for Australian high-risk children (HRC), compared to a recommendation from a primary care physician. HRC, including those with medical comorbidities, have frequent contact with hospitals, and free influenza vaccines have been available to some HRC as part of the National Immunisation programme since 2010. However, missed opportunities to vaccinate occur, and influenza vaccine uptake among Australian HRC is suboptimal. Thus, the researchers conducted a qualitative study involving health care workers (HCWs) at a large Sydney paediatric hospital to understand what is happening around influenza vaccination of HRC.

Between April and July 2018, the researchers interviewed 17 HCWs (9 doctors, 8 nurses), the majority (14/17) of whom had themselves received the influenza vaccine in 2017. Key themes included:

• Participants who were motivated to promote the vaccine often spoke of witnessing the impacts of influenza among their paediatric patients. There was a readiness to speak about influenza unprompted, as well as resolution to continue to discuss the vaccine with parents.
• It was suggested that it was important for an influenza vaccination recommendation to come from the hospital HCW, as it was perceived that parents have high levels of trust in these personnel.
• HCWs felt there was greater awareness and acceptance amongst parents whose children have more serious health conditions. Concerns about safety and effectiveness were suggested as being common reasons for hesitancy, as were misconceptions surrounding the rationale and need for influenza vaccination.
• Participants expressed difficulties in keeping up with the recommendations; they felt there was little guidance on vaccine issues and were unsure about where to acquire information and/or how to find information within the hospital's intranet.
• The issue of competing priorities was not uncommon when it came to staff members remembering to speak to parents about the vaccine.
• Hospital patients were described as a "captive audience" who were "more likely to act" if they were offered the vaccine. While general practitioners were acknowledged as the drivers of immunisation in the community, participants expressed concerns about relying on primary care. Participants had also received reports from parents that some general practitioners were reluctant to administer the vaccine due to the child's underlying condition.
• Several practical barriers to the delivery of the vaccine in the hospital's outpatient department were highlighted, including a lack of time, staff, and dedicated space.
• Increasing awareness about the recommendations for influenza vaccination and the onsite strategies to vaccinating children was suggested as first steps to improve practices. Methods of distributing information that were suggested were: sending text messages and emails, including reminders with the appointment letter, sending a letter to the patient's general practitioner, using channels such as newsletters and websites, and incorporating visual reminders. Nevertheless, there was concern about providing mass information as HRC may have conditions that impact the timing and appropriateness of their vaccinations.
• Several participants considered their colleagues capable of navigating discussions and did not believe additional training would be necessary. One, however, felt extra training would benefit HCWs with limited exposure to influenza and infectious diseases.

In reflecting on the findings, the researchers note that staff members who were responsible for caring for children hospitalised with influenza were those who were more likely to consider conversations about vaccination as an "ingrained" element of their consultations. They also seemed more willing to have multiple follow-up conversations with parents and had systems in place to get the children vaccinated onsite. This is important, as higher coverage has been seen when clinicians continue to nudge parents in spite of resistance.

The researchers stress that, given that HCWs often lack the time and capacity to conduct their own research, they need to have easy access to educational material and resources. Posters are often not seen on walls, while printed materials may get sidelined. (However, to support parents to speak up about the vaccine, there is still value in having promotion materials (in a range of languages) at the healthcare facility. Also, as there is limited time for patient education during consultations, educational tools (e.g., fact sheets) may assist HCWs in communicating the need for vaccination.) In this setting, having in-service sessions that include tailored information about the current recommendations, delivered at the department level, may be useful for HCWs, in addition to information sessions delivered throughout the influenza season at the hospital level. Having a vaccination champion within each department may also support staff to promote and/or deliver vaccines.

In conclusion, the researchers suggest that a "bundle approach" seeking to reach both HCWs and parents is likely required to achieve optimal vaccine coverage in the hospital setting. This would involve: (i) educating HCWs on the current recommendations for HRC; (ii) motivating HCWs to discuss the influenza vaccine in all consultations; (iii) increasing engagement with parents, and (iv) offering additional resources to allow more streamlined vaccine delivery.