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The effect of patient characteristics upon uptake
of the influenza vaccination: a study comparing
community-based older adults in two healthcare
systems
VIVIENNE LYNDA SHIRLEY CRAWFORD1, ANN O’HANLON2, HANNAH MCGEE2
1
Geriatric Medicine, The Queen’s University of Belfast, Whitla Medical Building, 97 Lisburn Road, Belfast BT9 7BL, UK
Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
2
Address correspondence to: V. L. S. Crawford. Email: [email protected]
Abstract
Background: the uptake of influenza vaccination represents a simple marker of proactive care of older people. However,
many still do not receive the vaccine. To understand this challenge better, we investigated the relationship between patient
characteristics (demographic, physical and psychological health and health service use) and vaccination uptake in a sample
of community-dwelling older people in two adjacent but differently structured healthcare systems (Northern Ireland (NI)
and the Republic of Ireland (RoI)).
Methods: a total of 2,033 randomly selected community-dwelling older adults (65 years and older) were interviewed in
their homes.
35
V. L. S. Crawford et al.
Results: rates of uptake were 78% in NI and 72% in RoI. The uptake was greater with older age (odds ratio (OR) 1.6,
95% confidence interval (CI) = 1.3–2.1, P < 0.0005), widowhood (OR = 1.5, 95% CI = 1.1–2.3, P = 0.02), living in NI
(OR = 0.77, 95% CI = 0.6–0.9, P = 0.04), greater functional impairment (OR RoI 2.0, 95% CI = 0.8–3.5, P = 0.03), more
frequent use of family doctor (OR RoI 0.5, 95% CI = 0.3–0.6, P = 0.0001; NI 0.6, 95% CI = 0.4–0.9, P = 0.01) and greater
use of services such as chiropody (OR NI 0.6, 95% CI = 0.4–0.9, P = 0.01), meals-on-wheels (OR RoI 1.3, 95% CI = 0.4–
2.2, P = 0.03), social work (OR RoI 1.2, 95% CI = 0.3–1.9, P = 0.05) and occupational therapy (OR RoI 1.3, 95% CI =
0.5–2.5, P = 0.02).
Conclusion: the uptake rates in both healthcare systems exceeded targets. Higher rates of vaccination were found among
older people, those who were married and those who made greater use of hospital and community services. Increased
exposure to health services may enhance trust in health care leading to higher vaccination uptake.
Keywords: influenza vaccines, older people, health services evaluation
Introduction
Influenza vaccination is a beneficial and cost-effective
method of reducing and preventing morbidity and mortality
among people at increased risk of complications from influenza [1–3]. Uptake of the vaccination represents a simple
marker of proactive care of older people.
Influenza vaccination has been recommended in the
UK since the 1960s. It was first offered to people of all
ages with underlying health conditions and to those in institutional settings where rapid spread could occur [1]. In
1998, the programme was extended by the Department of
Health for England who recommended routine vaccination
for those aged 74 years and older. From 2000, this was
further extended to include those aged 65 years and older,
regardless of their medical risk [4]. In Northern Ireland
(NI), the vaccination programme was aligned with the UK
in 2000, and a minimum uptake target of 65% was set. The
public were extensively informed about the vaccine.
Provision by primary care physicians was reimbursed and
was free at the point of care to patients.
The Republic of Ireland (RoI) followed the UK in
2006/2007 with guidelines and targets of 65% uptake for
those aged 65 years and older [5]. In RoI, a mixed system
of reimbursement for primary care physicians exists.
During the study, all patients aged 70 years or over were
treated free of charge. Those aged 65–69 years either had
universal health care (33%) or would have been charged for
the vaccination visit to the doctor.
Despite the long-standing availability of the vaccine,
large variations remain in vaccine uptake across countries.
The USA and Spain have good uptake among older adults
(averaging 65%), whereas rates in Poland average 18% [6].
Among those aged 65 years and over in the UK, the
uptake rates for 2007 were 75%, whereas in RoI the uptake
was significantly lower (63%) [7]. The UK has shown an
improvement of 7% in uptake since 1996 while the
Republic’s improvement was just 0.8%. In RoI, a cohort
study of 193 people reported an improved uptake of 24%
following invitation to attend for vaccination. This
improved a further 8% when followed by a reminder.
Overall, an uptake of 74% was achieved [8].
36
One study found higher uptake among older people,
those with chronic disease, those residing in large towns,
non-smokers and those with lower self-perceived health [6].
In the UK, the uptake was lower among women, the very
old and those in more deprived areas [9]. The finding that
men were more likely to receive the vaccination was supported by a later study [10]. Those who were married (or
living with others) were also more likely to be vaccinated
[10, 11]. Although many studies show some factors related
to uptake rates, little concordance exists regarding the influence of common patient characteristics such as age, gender
and marital status upon influenza vaccination uptake.
Knowledge and beliefs of older people are important in
their decisions to have influenza vaccination [12].
Promoting the vaccination on the basis of age can have
‘unintended negative consequences’ among healthy older
people whose self-perception of health is challenged by this
inadvertent ‘ageism’ [12].
With respect to other influences on vaccination uptake,
one study suggested that their reported increase in uptake
over a 10-year period was primarily due to the greater
intensity and effectiveness of promotion campaigns and a
higher participation by health professionals [6]. This idea is
widely reported [15, 16] and prompting, particularly from
health care providers, was the most significant motivator to
attend for vaccination [12]. Patient and physician attitudes
have also been reported to have an effect on uptake rates
[17]. Those with higher socio-economic status and those
with ease of travel to primary care physicians were also
more likely to have received the vaccine [9–11].
Receipt of funding to primary care physicians and the
setting of targets by the Departments of Health have been
the key factors in achieving vaccination. Additionally, the
importance of a robust patient record system to assist in
patient identification and thus an increase in the uptake of
the vaccine has been highlighted [8, 18].
Concerns remain about those who may miss out on this
important health promotion service, and whether this ‘absenting’ group is also likely to miss out on other health services.
Given the wide coverage of information about the influenza
vaccine, media attention to pandemics, avian and swine flu,
The effect of patient characteristics upon uptake of the influenza vaccination
the free nature of the vaccine to most patients and the potential benefits, it has been suggested that patient characteristics
are more important factors predicting uptake [11].
An age-related decline in uptake after the age of 85
years was reported in NI, but medical reasons increased the
uptake regardless of age [13]. The suggestion was that older
patients resident in elderly care homes were less likely to be
vaccinated. These are the very places requiring full coverage
[1] given that around 50% of the mortality resulting from
influenza is among such residents [14]. An alternative explanation was that the lower uptake rates at older ages resulted
from the healthy survivor effect leading to a reduced desire
for vaccination [13].
The present study aimed to examine patient characteristics influencing the uptake of influenza vaccination in
community-dwelling older adults in two healthcare systems.
Specific objectives were: (i) to assess any impact of sociodemographic and health measures on uptake rates (including urban/rural living, smoking status, physical factors and
psychological factors); (ii) to examine the relationship
between vaccine uptake and use of other services and (iii)
to examine the potential impact of vaccine uptake across
two healthcare systems.
list their understanding of why; not knowing they were
entitled to it, not believing it would reduce the risk of influenza, their doctors not suggesting it, already having had
influenza the previous year, their doctors indicating they
did not need the vaccine, concerns about side effects, previous negative experiences with ‘flu injection’ and any other
reason.
Physical health
Functional disability was assessed using the valid and
reliable Health Assessment Questionnaire Disability Index
(HAQ-DI) [21, 22]. Scores range from 0 (self-sufficient) to
3 (severely disabled).
Psychological health
Depressive symptoms were used as an index of psychological health. The widely used seven-item depression subscale
of the Hospital Anxiety and Depression scales (HADS-D)
performs well in assessing depression severity [23–25].
Higher scores reflect higher levels of depression.
Health service use
Methods
Sample
A total of 2,033 people (age range 65–102 years) participated in the study (1,000 NI; 1,033 RoI). Eligible participants (65 years or more) were identified by the Register of
Electors (RoI) and postal address files (NI), enabling a
random selection of private households. Survey staff conducted interviews in participants’ homes following participants’ written consent, as approved by the institutional
research ethics committees.
Detailed information on the sample and its similarity to
population profiles can be seen elsewhere [19, 20]. For
descriptive participant information see Supplementary data
available in Age and Ageing online. Data were collected as
part of a multidisciplinary Healthy Aging Research
Programme, which aimed to examine the experience of
health and ageing among community-dwelling older adults
in Ireland.
Measures
Health services used in the past year, both community- and
hospital-based, were evaluated. Health screening or promotion activities were also queried ( professional advice on
smoking (for smokers) in the past year and blood pressure
and cholesterol assessment in the past 3 years).
Statistical analysis
As is standard with population surveys, the data sets were
statistically adjusted or ’re-weighted’ to compensate for the
over-representation or under-representation of population
subgroups. A satisfactory completion rate and subsequent
re-weighting meant that the results could be considered as
broadly representative of the general population in NI and
RoI.
Analyses were carried out using SPSS for Windows and
STATA. The χ 2 test was used to examine the univariate
relationship between the uptake of influenza vaccine and
demographic factors. Multivariate logistic regression was
used to examine the effects of health and social services
indicators on vaccine; variables controlled in these analyses
included age and marital status.
Socio-demographic variables
Age, gender, education, marital status, smoking status,
household income, residence with respect to healthcare
system and urban or rural location were recorded.
Influenza vaccinations
Participants’ receipt of vaccination the previous winter was
recorded. Those who were not vaccinated indicated from a
Results
Socio-demographic and health measures
Completion rate for interviews was 68%. The sample (n =
2,033) was broadly representative of the older population
profile in each healthcare region with a mean age of 74.1
years (SD 6.8 years) (Supplementary data are available in
Age and Ageing online). Forty-three percent were men, 44%
37
V. L. S. Crawford et al.
were married and 40% widowed. Typical of this age group
in Ireland, only 40% had completed second-level education
or above. Forty-three percent lived alone and 36% lived in
rural areas. Eighteen percent were current smokers.
Three quarters of the sample had been vaccinated the
previous year with a significant difference in uptake
between the two healthcare systems (n = 1,530, NI 78%
versus RoI 72%, P = 0.04). When adjusting for demographic variables, people were more likely to have been vaccinated if they were over 75 years old or if they were
widowed (Table 1). No other demographic differences in
uptake were found.
Using the HAQ-DI, 17% had moderate to severe functional impairment (n = 2,049, NI 25% versus RoI 10%).
Using the HADS-D, 20% had borderline/clinical
depression (n = 2,027, NI 23% versus RoI 17%).
In RoI, there was a greater uptake of vaccination among
those with greater functional impairment (odds ratio (OR)
2.0, 95% confidence interval (CI) = 0.8–3.5, P = 0.03).
However, other physical and psychological factors did not
influence the uptake rates (Supplementary data are available
in Age and Ageing online).
Reasons for non-uptake were varied; they included
‘didn’t believe it would reduce the risk of getting flu’
(6.6%), ‘concerned about side-effects’ (5.2%) and ‘previous
negative experience’ (2.6%).
Service use
In both NI and RoI, vaccine recipients attended their
family doctor more frequently, and were more likely to have
had blood pressure and cholesterol checks (Table 2).
Hospital service use did not impact on uptake.
Vaccination uptake was associated with greater use of
chiropody in NI (OR = 0.6, 95% CI = 0.4–0.9, P = 0.01),
and in the RoI, meals-on-wheels (OR = 1.3, 95% CI = 0.4–
2.2, P = 0.03), social work (OR = 1.2, 95% CI = 0.3–1.9,P
= 0.05) and occupational therapy (OR = 1.3, 95% CI =
0.5–2.5, P = 0.02) (Table 3).
Discussion
This study found that among community-dwelling older
adults in both NI and RoI, influenza vaccination uptake
was high (75%). This is among the highest reported levels
of uptake for this age group [26] and has reached the target
recommended by WHO for 2010. This also contradicts a
recent report of low uptake in RoI (46%) in the same age
group and urban community [27]; however these researchers had a small sample size. This study is one of the largest
of its type and the participation rate (68%) is comparable
with other previously published work [10]. It is, however,
cross-sectional in design, and thus inferences about associations between receiving vaccination and health outcomes
cannot be confirmed; for this, a prospective design is
needed.
This study identifies a relationship between vaccination
uptake, age and widowhood. The relationship between
uptake and increased age agrees with some earlier reports
[6] and contradicts others [11]. Our observation that
widowhood increases uptake is also contradictory to
Table 1. Demographic factors associated with receipt of vaccination
Socio-demographic variable
Received vaccine?
%
Unadjusted odds ratio
P
Adjusted odds ratio
P
No
Yes
27
24
73
76
1.1 (0.9–1.4)
0.16
1.0 (0.7–1.3)
0.97
30
19
70
81
1.7 (1.4–2.1)
0.000
1.6 (1.3–2.1)
0.000
30
24
20
70
76
80
Reference
0.70 (0.5–1.0)
0.57 (0.5–0.7)
0.053
0.000
1.3 (0.8–2.1)
1.5 (1.1–2.3)
0.22
0.02
28
21
72
79
1.4 (1.1–1.7)
0.001
0.88 (0.6–1.2)
0.49
26
26
74
74
1.0 (0.8–1.2)
0.99
0.95 (0.7–1.2)
0.69
24
27
76
73
0.86 (0.7–1.0)
0.20
0.87 (0.7–1.1)
0.27
22
28
78
72
0.71 (0.5–0.8)
0.002
0.77 (0.6–0.9)
0.04
....................................................................................
Gender (%)
Men (n = 882)
Women (n = 1,170)
Age (%)
≤74 years (n = 1,095)
>75 years (n = 957)
Marital status (%)
Married (n = 853)
Single (n = 225)
Widowed (n = 899)
Living status (%)
Lives with others (n = 1,154)
Lives alone (n = 883)
Social class
Higher (n = 741)
Lower (n = 1,268)
Home location
Urbana (n = 1,265)
Rural (n = 755)
Geographical location
N. Ireland (n = 1000)
RoI (n = 1.033)
a
Defined as areas of 1,500+ people.
38
The effect of patient characteristics upon uptake of the influenza vaccination
Table 2. Health care factors associated with receipt of vaccination
Socio-demographic variables
Northern Ireland
Received vaccine?
Republic of Ireland
No [% (n)]
Yes [% (n)]
Adjusted odds
ratio
No [% (n)]
Yes [% (n)]
Adjusted odds
ratio
3.7 (5.2, 0–50)
4.1 (6.2, 0–92)
0.6 (0.4–0.9)a
0.01
3.9 (3.8, 0–24)
5.8 (5.9, 0–84)
0.5 (0.3–0.6)a
<0.0001
92 (187)
78 (151)
97 (738)
87 (625)
2.9 (1.3–5.8)
1.9 (1.2–2.9)
0.003
0.003
90 (257)
78 (216)
99 (750)
85 (636)
15.5 (6.1–34.1)
2.0 (1.3–2.8)
<0.0001
<0.0001
9 (20)
17 (36)
10 (74)
16 (122)
1.0 (0.6–1.7)
1.0 (0.6–1.4)
0.73
0.83
11 (31)
12 (36)
12 (88)
16 (122)
1.0 (0.6–1.6)
1.2 (0.9–2.0)
0.88
0.24
23 (53)
28 (207)
1.1 (0.8–1.7)
0.14
18 (48)
20 (152)
1.2 (0.9–1.8)
0.25
P
Received vaccine?
P
....................................................................................
General practitioner services
Mean number of visits (SD,
range)
Health promotion services (%)
Had blood pressure check
Had cholesterol check
Hospital service use
Emergency department visit
Scheduled hospital in-patient
stay
Scheduled outpatient
appointment
Adjusted data control for age and marital status.
OR represents the proportion of people above and below the mean number of visits for the total sample (mean 4.4, SD 5.7). Therefore, ≤4 visits are compared
with 5+ visits to the GP.
a
Table 3. Health care factors associated with receipt of vaccination
Socio-demographic variables
Northern Ireland
Received vaccine?
Republic of Ireland
Adjusted odds ratio
No [% (n)]
Yes [ % (n)]
13 (29)
14 (33)
6 (15)
4 (10)
13 (105)
18 (154)
6 (51)
6 (47)
1.1 (0.7–1.9)
0.7 (0.05–1.2)
1.1 (0.6–2.3)
0.7 (0.3–1.6)
16 (42)
8 (19)
6 (13)
3 (5)
2 (1)
24 (208)
7 (53)
4 (37)
1 (13)
1 (4)
30 (71)
25 (49)
5 (12)
3 (8)
2 (5)
1 (3)
P
Received vaccine?
Adjusted odds ratio
P
No [% (n)]
Yes [% (n)]
0.59
0.27
0.74
0.35
9 (25)
3 (9)
1 (4)
1 (2)
15 (116)
8 (68)
2 (18)
1(13)
1.0 (0.5–1.3)
1.0 (0.5–2.9)
1.3 (0.4–2.2)
1.0 (0.5–2.9)
0.59
0.48
0.03
0.68
0.6 (0.4–0.9)
1.2 (0.7–2.5)
1.4 (0.7–2.8)
1.6 (0.4–4.9)
1.3 (0.1–9.1)
0.01
0.41
0.34
0.40
0.78
7 (24)
1 (2)
4 (12)
1 (4)
1 (4)
19 (142)
2 (12)
6 (43)
2 (12)
1 (11)
0.8 (0.3–0.7)
1.2 (0.3–1.9)
1.1 (0.4–1.7)
1.3 (0.5–2.5)
1.1 (0.6–3.0)
0.39
0.05
0.22
0.02
0.25
36 (287)
26 (191)
8 (63)
6 (43)
0.7 (0.5–1.0)
0.8 (0.5–1.3)
0.6 (0.3–1.3)
0.6 (0.2–1.0)
0.07
0.52
0.24
0.15
20 (58)
14 (38)
2 (6)
4 (13)
26 (189)
13 (98)
7 (55)
3 (29)
1.0 (0.6–1.2)
1.3 (0.7–1.8)
0.5 (0.3–0.9)
1.3 (0.5–2.1)
0.79
0.06
0.92
0.08
2 (19)
2 (15)
0.9 (0.1–2.7)
0.6 (0.3–2.8)
0.84
0.48
1 (3)
1 (2)
2 (12)
0 (1)
1.7 (0.6–5.3)
1.0 (0.1–15.5)
0.19
0.90
....................................................................................
Received in past 12 months
Home-delivered services
Public health nurse
Home help
Meals-on-wheels
Personal care attendant
Therapies
Chiropody
Social work
Physiotherapy
Occupational therapy
Psychology/counselling
Specialist services
Optical
Dental
Aural
Dietetic
Respite services
Respite care as a receiver of care
Respite care as a carer
Adjusted data control for age and marital status.
some earlier reports [10, 11]. Taking into account the
work of Evans et al. [12] and Telford and Rogers [28]
regarding the patient belief systems and decision-making
processes, one explanation is that both increasing age and
widowhood are indicators of potential vulnerability. It is
possible that older people living alone are more concerned about contracting influenza because of a lack of
informal support should they become ill. Additionally, the
absence of spousal influence may allow greater influence
of healthcare professionals and health promotion
activities.
With respect to the two regions examined here, possible
differences in health perceptions in the two populations
may contribute to vaccine uptake. Evans’ suggestion that
‘system values’ are adapted to work with ’patient values’
rather than attempt to override them is relevant to this
study where different ‘systems’ operate [12]. Here, increased
uptake was associated with functional impairment only in
39
V. L. S. Crawford et al.
RoI. This may result from a lifelong relationship between
patient and healthcare system and the potential cultural
difference where those in RoI are more affected by Evans’
‘negative consequences’ of targeting the vaccination on an
age basis.
Reasons for non-uptake of the vaccine were similar in
both healthcare systems, although RoI had fewer people
‘concerned about side effects’. Reasons for nonuptake can be summarised by a lack of belief in the
vaccine and concerns about side-effects, as found
elsewhere [28–30].
The literature also reports an inverse relationship
between need and receipt as with other preventive services,
and a greater uptake by those in urban areas [10]. We
found no difference between urban/rural uptake and a
positive relationship between receipt and use of certain
other services, particularly in RoI where a more mixed
public–private healthcare system operates.
In relation to the use of health-related services, we
found those in receipt of vaccination to visit their family
doctor more frequently. This supports a number of investigators who report increased uptake of vaccination in
association with promotion campaigns and participation
of health professionals [6, 8, 15, 16]. Holm et al. [26]
report that recommendation by the family doctor gives
the strongest motivation for vaccine uptake. Our report
also highlights the input of other health professionals in
both hospital and community services involved in caring
for the participants.
In conclusion, the present study represents one of the
largest samples examined in relation to influenza vaccination uptake. It provides a robust measure of the early
attainment of targets for the uptake of the vaccine in both
NI and RoI. It also adds to the literature by comparing two
healthcare systems on one island as an illustration of the
effect of healthcare policy and population differences on
influenza vaccination uptake. Cultural differences in the two
populations, together with the integration of health and
social services in NI, are proposed to have impacted upon
uptake.
However, there remains uncertainty regarding patient
characteristics that may or may not predict influenza vaccination uptake. The decision to receive the vaccination is
informed by the experience of influenza and health and
illness behaviours. One of the most important of these is
trust in modern medicine [28]. The significant findings of
this study, where uptake rates increased in conjunction with
the use of other hospital and community services, may represent evidence of exposure to and thus increased trust in
modern medicine, this in turn leading to increased uptake.
The beliefs of each population and influences upon these
beliefs are continually changing. Although we currently seek
to understand patient characteristics that act as barriers to
vaccination uptake, we may in future need to return to a
focus on need, as demand for vaccination becomes the
norm. The addition of the H1N1 virus to public debate
and to the primary care vaccination programme may
40
further influence attitudes and uptake to the regular influenza virus.
Key points
• The characteristic most associated with greater uptake of
influenza vaccine was higher health service use in the previous year.
• The characteristics associated with vaccine uptake varied
across two adjacent healthcare systems.
• Both healthcare systems achieved vaccination rates in
excess of their targets.
Acknowledgements
We thank the research team, Professor James Williams
(ESRI) and Dr Donal McDade (Social and Market
Research) for coordinating community interviews in the
Republic and Northern Ireland, respectively. We thank
those who assisted in the focus groups and those who took
part in the pilot, test-retest and main studies. We thank
other Healthy Aging Research Programme (HARP) staff
and Steering Group members who contributed in this
research: Prof. Ronan Conroy, Dr Rebecca Garavan, Dr
Anne Hickey, Dr Frances Horgan, Dr Karen Morgan, Dr
Emer Shelley (RCSI), Dr David Hevey (TCD), Dr Claire
Donellan, Prof. Richard Layte (ESRI), Prof. Robert Stout
(QUB) and Dr John Dinsmore (QUB). We also sincerely
thank research participants for their time and cooperation.
We are also grateful to Prof. Paul Baltes (deceased) (Max
Planck Institute for Human Development, Germany) and
Prof. Marie Johnston (University of Aberdeen, Scotland),
who were external advisors to the HARP Programme.
Conflicts of interest
None declared.
Funding
This work was supported by a Programme Grant from the
Irish Health Research Board [PRO23/2001]. The funder
played no role in designing or writing any part of this study
and report.
Supplementary data
Supplementary data mentioned in the text are available to
subscribers in Age and Ageing online.
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Received 24 November 2009; accepted in revised form
23 September 2010
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