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Student and faculty perceptions about mandatory influenza vaccinations on a health sciences campus.
Every year, 5–20% of Americans are diagnosed with influenza. Mortality rates vary from 3,000 to 49,000 per year in the United States with the large majority of deaths occurring in adults of 65 years and older. The Centers for Disease Control and Prevention recommends influenza vaccination in everyone 6 months or older without contraindications. Health care personnel are designated as one of the groups at higher risk for influenza-related complications.[ 1] Mandatory influenza vaccination policies for hospitals and health systems have emerged as a way to increase immunization rates among this population. Overall, influenza vaccination rates among health care personnel have been less than optimal with an estimated vaccination rate of 77.2% for the 2015–2016 season with the highest vaccination rate observed in those with a mandatory requirement (vaccination rate of 96.5%).[ 2] Health care personnel may unintentionally expose patients to influenza because the virus can spread for 1 day prior to symptom onset and up to 5–7 days after symptom onset. Improving health care personnel vaccination rates may decrease the spread of the influenza virus to patients and other health care personnel as well as avoid work absenteeism.[ 1]
Every year at the University of Oklahoma Health Sciences Center (OUHSC), campus-wide, pharmacy-delivered influenza vaccination clinics are offered at multiple locations throughout the month of October to provide no-cost, convenient vaccinations to the faculty, staff, and students. The OUHSC is a comprehensive health sciences center encompassing seven colleges (pharmacy, medicine, dentistry, nursing, allied health, public health, and graduate), two hospitals, numerous adult and pediatric specialty clinics, and various research centers. Our campus-based influenza vaccination clinics have been described in detail previously in the literature.[ 3] Physician faculty as well as all employees and students working within the campus hospitals have a mandatory requirement to receive the influenza vaccination or submit documentation for a contraindication. A tamper-resistant sticker affixed to the name badge is used throughout influenza season to show proof of current immunization status. Those not in compliance with the vaccination mandate are required to wear a mask in patient care areas for the duration of the influenza season. Perceptions of both current and future health care personnel regarding mandatory vaccination policies are relatively unknown. The goal of this investigation was to examine perceptions among health care faculty and health professional students regarding mandatory vaccination policies on the OUHSC campus.
Methods
In October 2015, coordinators of the influenza vaccination clinics emailed an electronic survey to the entire OUHSC campus, including 1,431 faculty and 3,379 students. The initial email invitation to participate in the survey explained the purpose of the study and included a link to the survey hosting website, Qualtrics, where individuals needed to consent to participate. During the clinic times, candy incentives and paper invitations to complete the survey were handed out to all who were vaccinated. A modified electronic Dillman method was used for distribution of the survey with campus-wide reminder emails sent at day 17 and day 30 following the conclusion of the vaccination clinics.
Previous studies have been completed assessing medical students’ and health care professionals’ attitudes or beliefs about recommended and mandatory vaccination using similar methods.[[ 4]] This study’s survey items were based on review of prior literature of mandatory vaccination requirements in health care settings and student and health care personnel beliefs.[[ 4]] Survey revisions were made through an iterative, item-review process for face and content validity by the pharmacy faculty who coordinated the vaccination clinics and graduate students involved in the research project.
The survey included 20 response items associated with times, places, and preferences associated with receiving an influenza vaccination at a campus clinic as well as perceptions of a mandatory influenza vaccination policy. No demographic data beyond the individual’s role as a student, faculty member, or staff were included. Individuals who did not receive an influenza vaccination at a campus clinic were not able to take the survey. Specifically, the survey included five items that assessed perceptions of employer-mandated vaccination policies. Where applicable, a 4-point Likert-type scale of agreement was used (e.g., strongly agree/somewhat agree/somewhat disagree/strongly disagree). Participants were asked to select their level of agreement with five statements regarding mandatory influenza vaccinations: (a) I believe mandatory influenza vaccination is appropriate for a heath care work environment; (b) I would still get the influenza vaccination if there was NOT a mandatory vaccination requirement; (c) I believe health care employees obtaining the influenza vaccination have a positive impact on their patients’ health; (d) I believe a health care employee NOT obtaining the influenza vaccination has a negative impact on patients’ health; and (e) A mandatory influenza vaccination requirement would make me consider other employment. Faculty also identified whether mandatory influenza vaccination requirements for their respective place of employment exist. Additionally, all participants identified whether they had direct patient care associated with their employment or academic responsibilities. Electronic survey data were incorporated into and analyzed utilizing SAS v.9.4 (Cary, NC). An a priori level of α = 0.05 was set for determining statistical significance. Univariate analysis and differences between group responses to Likert-type items were determined by chi-square analysis.
Participants who provided their contact information after submission of their survey were entered into drawings for one of five fitness trackers. The OUHSC Institutional Review Board granted approval for the conduct of this study.
Results
Of the 2,533 individuals who received an influenza vaccination at an on campus clinic, a total of 1,672 participants completed surveys, giving a response rate of 66%. A total of 948 students and a combined 1585 faculty and staff received an influenza vaccination from a campus clinic. A subset of the 296 faculty and 244 student surveys were included for the analysis. Surveys from staff or others were excluded from the analysis so that faculty and health professional student perceptions could specifically be evaluated.
Direct patient care within either employment or academic responsibilities was reported in more students (77.37%) than faculty (68.14%) (p = 0.0173). Additionally, a mandatory requirement to receive an influenza vaccination from either their employer or academic assignment was reported more commonly in students (74.49%) compared to faculty (67.69%) (p = 0.0086).
Four survey items specifically related to perceptions regarding mandatory vaccinations are summarized in Table 1. Both students and faculty either somewhat or strongly agreed that mandatory influenza vaccination is appropriate for the health care work environment (p > 0.05). When comparing students (79.67%) to faculty (94.94%), more faculty either somewhat or strongly agreed that they would still get the influenza vaccination if there was no mandatory influenza vaccination requirement (p 0.05) and that health care employees who did not obtain the influenza vaccination had a negative impact on their patients’ health outcomes (p > 0.05). An additional chi-square analysis that separated out faculty and students who had direct patient care showed similar results. The final question specifically addressed faculty agreement to a mandatory vaccination policy since no student responses were allowed. A majority of faculty (97.27%) would not consider other employment options due to the implementation of a mandatory influenza vaccination policy, while a minority (2.73%) would consider other employment options.
Table 1. Perceptions of mandatory influenza vaccination.
Overall
Only those with direct patient care
Students n (%)
Faculty n (%)
p-value
Students n (%)
Faculty n (%)
p-value
Mandatory flu vaccination is appropriate for a health care work environment
Strongly or somewhat agree
229 (95.0)
274 (92.9)
0.6676
177 (95.2)
188 (94.0)
0.9576
Strongly or somewhat disagree
12 (5.0)
21 (7.1)
9 (4.8)
12 (6.0)
I would still get the flu vaccination if there was NOT a mandatory vaccination requirement
Strongly or somewhat agree
192 (79.7)
281 (94.9)
<0.0001
144 (77.4)
190 (94.5)
<0.0001
Strongly or somewhat disagree
49 (20.3)
15 (5.1)
42 (22.6)
11 (5.5)
Health care employees obtaining the flu vaccination has a positive impact on their patients’ health
Strongly or somewhat agree
235 (96.7)
285 (96.9)
0.2281
180 (95.7)
193 (96.5)
0.4115
Strongly or somewhat disagree
8 (3.3)
9(3.1)
8 (4.3)
7 (3.5)
Health care employees NOT obtaining the flu vaccination has a negative impact on patients’ health
Strongly or somewhat agree
195 (79.9)
239 (80.7)
0.5184
147 (78.2)
163 (81.1)
0.6427
Strongly or somewhat disagree
49(20.1)
57(19.3)
41 (21.8)
38 (18.9)
Comment
The findings of this investigation give insight into the perceptions of health care faculty and health professional students about mandatory vaccination policies. Specifically, no difference between these two groups was found in their agreement that mandatory influenza vaccination policies are appropriate. These findings support the appropriateness of mandatory influenza vaccination policies, which has been supported in previous studies as being effective at increasing vaccination rates.[[ 7]] Similarly, Durando and colleagues surveyed 830 health care workers’ attitudes and beliefs of seasonal influenza vaccine uptake and found that those who agreed with the statement “I believe that mandatory flu vaccination should be implemented in health care settings” were significantly associated with increased influenza vaccination rates.[10]
Additionally, no difference between the two groups was found concerning agreement that the influenza vaccination positively impacts patients if received by health care workers and the lack of influenza vaccination of health care workers negatively impacts patients. The perception of both students and faculty about the positive impact of receiving the influenza vaccine supports previous research by Godoy and colleagues where the vaccination of physicians was found to be a possible predictor of vaccination uptake by their patients.[11] Results from Godoy’s survey analyzed responses from 815 physicians and showed that influenza coverage was higher in those patients whose primary physicians had also received the influenza vaccine (57.3% versus 55.2%, p = 0.008).[11]
Although a majority of both faculty and students agreed they would still receive the influenza vaccination without a mandate, fewer students would get the vaccine compared to faculty. A number of factors could be playing a role in this difference as noted in previous research. Kelly, Macy, and Mak investigated factors associated with receiving annual influenza vaccination using an online survey of 438 students from multiple health-related fields (e.g., medicine, nursing, physiotherapy). They reported that convenience and awareness of influenza vaccination policies was a key enabler to increase student influenza vaccination rates.[12] Additionally, Bednarczyk and colleagues surveyed 600 students and found that healthy students tend to not perceive a need for influenza vaccine.[13]
The final result obtained through this investigation pertained to faculty employment decisions based on mandatory vaccination policy. About 97% of faculty would not consider leaving their current place of employment, while only 3% would consider other employment options. Literature on the dilemmas presented by mandatory vaccination policies has been previously published by Tilburt and colleagues. Their discussion of the ethical principles of beneficence, nonmaleficence, autonomy, and justice ended with the conclusion that mandatory vaccination policies were supported and outweighed the health care worker’s autonomy in light of public safety.[14] In a discussion of the ethical implications of mandatory vaccinations, Van Delden and colleagues similarly concluded that vaccination is important for safety and improved health.[15]
Limitations
Despite finding significant differences among the preferences for mandatory influenza vaccination between students and faculty, our chi-square analyses limit the robustness of the findings since the substantive significance of the differences cannot be clearly established. Only individuals receiving the influenza vaccination were analyzed, so an inherent bias toward getting the vaccine may influence these results. The low percent of student responses and inability to differentiate staff and faculty from each other limit the generalizability of the results and may be associated with nonresponse bias. Gathering more information about the participants would have allowed for more rigorous analysis. Additionally, students and faculty from several different colleges (e.g., medicine, dentistry, pharmacy, etc.) participated in the study with differences between those individuals and colleges not taken into account. Without college- and individual-specific information, demographic- and curriculum-based differences could not be assessed. Finally, the study results may be limited in generalizability to similar health sciences center campus settings and structure.
Conclusions
Overall, health care faculty and health professional students had favorable perceptions about mandatory influenza vaccine policies. Since students were less likely to be vaccinated in the absence of a mandate, improvements should be made in the education of health professional students about influenza vaccination benefits, misconceptions, and how their receipt of the influenza vaccine helps prevent illness their colleagues and patients. Improving the understanding of how current and future health care professionals view mandatory influenza vaccinations can help inform development and refinement of future influenza vaccination policies. Additionally, gaining a better understanding of why the small portion of employees who would consider other employment due to mandatory vaccination policies could assist in finding reasonable alternatives to ameliorate those issues.
Conflict of interest disclosure
The authors have no conflicts of interest to report. The authors confirm that the research presented in this article met the ethical guidelines, including adherence to the legal requirements, of the United States and received approval from the Institutional Review Board of The University of Oklahoma.
Funding
No funding was used to support this research and/or the preparation of the manuscript.
By Philip Looper; David George; Eric J. Johnson and Susan E. Conway