Health Education Research, Vol. 18, No. 6, 743-753,
December 2003
© 2003 Oxford University Press
What influences elderly peoples’ decisions about whether to accept the influenza vaccination? A qualitative study
Robert Darbishire Practice, Rusholme Health Centre, Manchester M14 6NP and 1 School of Primary Care, University of Manchester, Rusholme Academic Unit, Manchester M14 5NP, UK
e-mail: rtel{at}gp-p84072.nhs.uk
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Abstract |
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Influenza and its related illnesses remain a major cause of preventable morbidity and mortality in the elderly worldwide. The current influenza vaccine campaign in the UK is only a partial success despite annual costly publicity campaigns. The aim of this study was to explore the influences on decision making by elderly people for influenza vaccine uptake. Twenty patients age 75 years and over were purposively selected from those eligible for influenza vaccination in an inner city general practice in England. In-depth qualitative interviews were conducted with 10 patients who accepted and 10 who refused the vaccine. Those interviewed were concerned about maintaining their health, and had a good understanding of influenza, its transmission and prevention. The decision whether to accept or refuse the influenza vaccination was influenced by trust or mistrust of modern medicine, prior experience of vaccination and perceived risk from influenza. Newly acquired lay experience and personal perceived risk from influenza seemed to be more important catalysts for the change in vaccination uptake than professional recommendation or advertising by official government health agencies. In order to improve uptake rates, the official message promoting vaccine uptake needs to take more account of lay knowledge and the subjective assessment of risk.
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Introduction |
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Despite a safe, efficacious and cost-effective vaccine being available (Margolis et al., 1990
; Govaert et al., 1993, 1994; Mullooly et al., 1994; Nichol et al., 1994; Gross et al., 1995; Christenson et al., 2001), influenza and its related illnesses remain a major cause of morbidity and mortality in the elderly. In England and Wales it is estimated that 12 000–13 800 deaths a year can be attributed to influenza (Nicholson, 1996; Tillett et al., 1996; Fleming, 2000), of which over 80% occur among people over 65 years of age (Nicholson, 1990). In England alone, there are 3028 excess respiratory hospital admissions in the 65- to 74-year-old age group and 6049 in those aged 75 and over (Fleming, 2000).
In the UK, the policy of encouraging influenza vaccine uptake in the elderly and those identified as ‘at-risk’ groups is seen as a central tenet of managing winter pressures in the National Health Service and preventing ill health amongst older people. In 1998 it became part of the governments’ public health policy to offer annual influenza immunization to those aged 75 years and older (Department of Health, 1998); in 2000, this policy was extended to all people age 65 and over (Department of Health, 2000). The national average uptake achieved for the winter 2001/2002 in this age group was 68%. The Department of Health’s current policy is to aim for further increases in uptake (Department of Health, 2002). Despite the efforts of primary care professionals and public health agencies, higher targets are not likely to be met. Thus encouraging uptake and understanding barriers to influenza vaccine acceptance amongst elderly people are likely to remain highly relevant to this government priority. Previous research suggests a number of reasons for ‘non-compliance’ with influenza immunization (van Essen et al., 1997; Pregliasco et al., 1999; Findlay et al., 2000; Gosney, 2000); these include fear of side-effects, lack of confidence in effectiveness of the vaccine, fear of needles, disbelieve in seriousness of flu and personal susceptibility. Insightful though this research is, it is likely to provide only part of the picture as to what influences the uptake of the vaccine amongst elderly people. Personal experience and knowledge has been shown to be central to the understanding and acceptance of health promotion, advice and interventions in relation to other conditions (Pill et al., 1985; Davison et al., 1991). Qualitative research into uptake of childhood vaccination (New and Senior, 1991; Rogers and Pilgrim, 1995; Marshall and Swerissen, 1999) has illuminated the relevance of exploring in-depth peoples’ understanding of the cause of illness, and the subjective assessment of the risks and benefits of the immunization for vaccine uptake.
A number of influences relevant to the acceptability and uptake of the mass childhood immunization (MCI) programme are likely to be applicable to the uptake of the influenza vaccination programme [e.g. perceptions of the immunization process, contact with health professionals and motives of official health policy makers, the provision of balanced and comprehensive information, relevance of a risk balancing framework which takes account of perspectives on personal lifestyles, salutogenic influences, and alternative means of prevention (Rogers and Pilgrim, 1995; Bond et al., 1998; Sporton and Francis, 2001)]. However, the salience of these factors in relation to the influenza vaccination programme which is targeted at a different population group has not previously been explored and a number of issues are likely to be different. The MCI programme, for example, is predicated strongly on the notion of ‘herd immunity’ (i.e. immunization uptake is linked to a population-level risk reduction measure). Additionally, risk assessments are made by proxy in so far is it is parents (usually mothers) assessing risks to their child. Both of these issues have less salience in the case of the uptake of influenza vaccine. There are no similar qualitative studies in relation to influenza vaccine uptake in the elderly and little is known about the risk calculations or factors older people take into account when deciding to reject or accept flu vaccination offered to them in primary care.
This research study arose from an audit within a general practice where one of the authors (R. T.) works. The audit showed that despite personal postal invitations, a high-profile practice campaign promoting the vaccine, dedicated ‘flu’ clinics and home visits for the elderly, 41.7% of those aged 75 and over chose not to have an influenza vaccination for the winter 1999/2000. The purpose of the study was to analyse in depth the influences on elderly people to accept or refuse the influenza vaccine, and thus inform the author’s practice as well as primary care practice and policy making more generally.
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Methods |
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In March 2000, 216 patients aged 75 years and over who had been eligible for the influenza vaccine for the winter of 1999–2000 were identified from a computer search. The clinical records of the study population were scrutinized to identify those who had accepted and refused the vaccine in order to identify potential patients eligible for inclusion into the study. After applying the exclusion criteria as shown in Table I, a sample of 118 remained. A purposeful sampling strategy was adopted and participants were recruited by means of a personalized letter of invitation from R. T. Twenty patients were subsequently interviewed, 10 who had accepted influenza vaccine and 10 who had refused. (Interviews were discontinued once saturation of the themes was achieved.) The characteristics of the sample are shown in Table II. During inspection of the records it became evident that in addition to those who accepted and refused the vaccination, there were a further two groups; those who had initially accepted the vaccination, but then subsequently refused it and those who initially refused the vaccination, but then changed their minds to accept it (Figure 1).
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Semi-structured in-depth interviews using a topic guide (Table III) were conducted (by R. T.), according to the individuals’ preference either in their homes or at the surgery, the emphasis being on encouraging the interviewee to talk, and give their views and opinions. Uninterrupted the interviews lasted between 20 and 45 min.
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Data analysis
The interviews were tape-recorded with the patients’ permission and transcribed verbatim by R. T. Aspects of grounded theory and constant comparative method guided the data collection analysis (Glaser and Strauss, 1967
). The interviews were coded manually using summary sheets for each interview to document the emerging themes. Examples to illuminate theoretical concepts were identified and links were made between associated categories. For example, comparisons between and within the accepting and refusing groups were made, and particular comments that supported or contradicted the main themes were noted. The accounts from the respondents who changed their uptake status (Figure 1) were of particular importance in shedding light on the decision-making process. Subsequent interviews with respondents were used to check, add to and elaborate these identified themes. In order to retain the continuity of meaning and context between data collection and qualitative analysis R. T. reviewed and coded the transcripts (Morse, 1997). Codes and emergent themes were discussed and checked on an ongoing basis with A. R. |
Results |
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The importance of healthy living
Elderly respondents’ perceptions of immunization against influenza took place against a backdrop of established norms and values about healthy living, and its role in preserving health and fending off illness. Whilst for a small minority of respondents (n = 2) genetics and family histories were seen as key determinants of good or bad health, behaviours and lifestyles which had been established over many years were for most seen as having the greatest salience for the prevention of illness and promotion of health. Issues seen as particularly important across the groups were the benefits of healthy eating, fresh air, keeping active, not smoking and drinking alcohol in moderation.
A good diet was seen as particularly important in the preservation of health:
Well I would think that we try to eat a reasonable, a balanced diet...oh, plenty of fruit and vegetables. Fish I think is a good thing, I don’t eat a great deal of meat, but I do eat some. Avoidance of too much fat or too much sugar, too much salt. [Acceptor who became a Refuser]
Notions of healthy eating and its relationship to physical health had been established over a lifetime and passed down through the generations as indicated by this response:
My father had a saying, which he repeated again and again: ‘it is better to pay the butcher and the baker than the doctor’... I still continue today in the way my father and mother brought us up, meat fish vegetables... [Acceptor]
Three key themes were identified from individuals personal accounts about what influenced their decision making about influenza vaccine uptake. These were: trust or mistrust in modern medicine, prior experience of vaccination and perceived risk from influenza (Figure 2). The themes combined to influence the uptake decision, although one theme could usually be identified as the most prominent.
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Theme (a): trust and mistrust in modern medicine
The narratives from those accepting and refusing the vaccine offered differing views across a spectrum of trust and mistrust. For those accepting the vaccine, faith and trust in modern medicine influenced agreement to accept the offered immunization:
Well I would say, if you get recommendations from the Government and the medical profession and they both urge you to do these things, well do ‘em... [Acceptor]
Even the reported experience of side-effects by some from the initial vaccination did not seem to weaken this trust:
...the first time, I had it on the Tuesday morning and the Tuesday night I was out with my sisters and some friends, ooh and I went real queer... I went shivering, shaking, so I left them, and got a taxi home and took a couple of powders and went to bed. The next morning I was as right as rain, and I‘ve had it twice since then and it’s never affected me. [Acceptor]
In contrast, those refusing the vaccine were generally more sceptical about medical advice and the benefits of having the vaccine:
I wonder just how effective this stuff (flu vaccine) is? Now as well as not liking Doctors and er hospitals, er I’m a bit dubious about the whole of the drug profession... [Refuser]
...I think we’ve all got this natural immunity to disease and I think unless you start interfering with it, vaccinations, inoculations and all that, I think it will work, but I think given enough of these er, um, antibiotics, vaccinations I think it will probably pack in. [Refuser]
Individuals (see Figure 1) who had changed their minds described how their views altered over time. A number of individuals had accepted the vaccine on one occasion, but their faith in the benevolence of the vaccine was eroded after experiencing a perceived vaccine reaction (Theme b) and they subsequently refused further vaccinations. They reported how these experiences had led to a greater mistrust of professional advice, and a preference for a reliance on a healthy lifestyle and avoiding contact with the illness as their means of preventing flu:
...keep away from people, you know, because I think myself, what gives you flu if you don’t have the needle, I think you get flu by being with a lot of people you see. [Acceptor who became a Refuser]
The antithesis was evident in the respondents who initially refused the vaccine. They, like those who still refuse the vaccine, initially mistrusted the professional recommendation to have the vaccine as their prior experience of vaccination and perception of risk from influenza lead them to believe that it was not necessary:
...it was purely that I didn’t like needles and people, you’d hear about these side-effects; all the side-effects you have from that flu jab ‘oh you can’t lift your arm and you’re sick’... [Refuser who became an Acceptor]
Their decision, however, reversed because of the awareness of a perceived increase in risk from the illness through personal experience or that of others (Themes b and c), this resulted in a more trusting and accepting view of professional and official advice about the benefits of vaccination. For one, a lifetime refuser of all vaccines, her experience of actually having influenza vaccine was a huge anticlimax:
...and I might of well as have a drink of water both times [referring to the two times she has had the influenza vaccination]... [Refuser who became an Acceptor]
Theme (b): prior experience of vaccination
Decisions about acceptance or refusal of the influenza vaccine drew not only on proximate factors, but also upon the accumulated experience at different points over the life course. For vaccine refusers, the experience of and perception of side-effects and poor efficacy of the vaccine assumed a central importance in decision making:
...‘I’m going to have it,’ [the flu vaccine] he [husband] said. ‘Oh I wouldn’t have it if I was you’ I said ‘because they give you a dose of it you see so somebody had told me’, and so he said ‘listen’ he said ‘I’ve had umpteen injections’ so he said, he was in India during the war for three and a half years you see, so I said ‘OK please yourself’ so he said ‘are you coming’ I said ‘no, no I’m not having it, there’s no way I’m having it’ you know, however he had it. Was he ill? ‘Gosh’ he said ‘never no more’ he said. ‘Well, I told you didn’t I’, yes I said to him. [Refuser]
On other occasions a non-acceptance decision was supported by reference to perceived problems with vaccines and the development of an anti-vaccination ethos at earlier points in a persons’ life:
...I was always against injections for some reason or other... I didn’t have D [daughter] immunized, so half the class got the diphtheria, diphtheria and of course, half the class got it and the girl who started with it, was sick on the same desk as D and she never got it and she hadn’t been immunized and half the class that had been immunized got it... [Refuser]
We had er, several injections, you know when you go in [The Armed Forces]...and I’d never been vaccinated as a kid; and er, they had to vaccinate me. Well, I got vaccine fever, have you heard of vaccine fever? ...Oh, that’s terrible that, it knocks you out just like that, only 3 days. [Refuser]
In contrast, of those who had always accepted the vaccination, the prior personal experience and those of their established social networks served only to re-enforce their decision for vaccine uptake:
It seems to be effective, a number of our friends have it and we compared notes with people who have had it and they’ve normally been people who’ve not had the flu. I mean people that we know who are our sort of circle, our age circle, people that we meet in our church and so on and so forth. Those that have had it, seem to have missed the flu. [Acceptor]
In those who initially accepted the vaccination, the subjective experience of a perceived vaccine reaction acted as a salient influence that convinced them to refuse subsequent vaccinations:
...after that I had a flu jab once and I got the flu and that lasted over a week, so I said to myself, never again, no more jabs...so I thought it’s no use having this stuff if it’s going to give me flu again. [Acceptor who became a Refuser]
Whereas for those who initially refused the vaccine, note was taken of reported experiences of others who claimed that the vaccine made them ill or was ineffective:
...that’s what I was frightened of, the ill effects...because I ‘d seen two or three people and they’d said they’d felt so ill after the injection and I think that was at the back of my mind. ...they just felt ill, they didn’t really describe it, they just felt ill and also they kept having the flu after it, worse than what they had before so I thought well that’s not good is it? [Refuser who became an Acceptor]
These reported experiences were rendered less influential when respondents encountered a perceived personal risk from influenza (Theme c), which acted to change their decision to accept the vaccine.
Theme (c): perceived risk from influenza
All of the respondents had had first- or second-hand experience of influenza as an illness and had elaborate views about its transmission and prevention. Again, combinations of distant and proximate factors were evident influences in the formation of the extent of risk posed. In keeping with the medical consensus, some respondents questioned the correct usage of the terms ‘cold’ and ‘flu’, and felt the term ‘flu’ was overused and often misunderstood:
You hear people say I’ve had the flu but I don’t think they’ve had it, they’ve just had a cold like and they think it is the flu... I’ve talked to people and they’ve said, ‘oh, I’ve had the flu’ and you know they’ve just had a cold because you know it knocks you out flu, doesn’t it? [Acceptor who became a Refuser]
Thoughts on how influenza is contracted included ideas involving germs or viruses, something in the air, contact with ill people, breathing in the air in crowded places, going out in bad weather, getting wet and cold, spitting, and drinking out of bottles:
Well, breathing something up your nose, er...even I should imagine even touching something if they had just blown their nose and you touched it you could get it by going and touching your nose or face um...chiefly I should think by breathing in air in a cinema, I don’t go to cinemas anymore, breathing in air in a cinema or a crowded place. [Acceptor]
Interviewees described how their chance of catching flu was reduced by avoiding crowded places and contact with people with respiratory illnesses. A perceived lack of risk from influenza was an important influence in those refusing the vaccine:
And you know, advertising on the wireless and the everything like the television, the flu vaccine have it and this and that, and I would think I’ve never had the flu, I’m not mothering. [Refuser who became an Acceptor]
In contrast, those accepting of the vaccine perceived themselves to be at risk from influenza and in some cases this was underscored by accounts of influenza which were not minor in their consequences:
...my mother before she was married had the Spanish flu, so I remember her telling me all about it. I dread that coming back, it wiped out apparently quite a lot of the population... So I wouldn’t like to get that kind of flu, I wouldn’t like to get any kind of flu really, so I’m all for having the vaccine...she said, eh that about half a dozen people in the road they died, actually died, apparently you could see funerals every day... [Acceptor]
...because if you’ve already got some illness, to have the flu on top of that is really going to knock you... So the older you get, the more you feel something, especially something like the flu or even a bad cold, you feel it a lot worse... You are going to be more ill, you are going to become a complete nuisance to someone else... [Acceptor]
For the individuals who altered their decisions, a change in the perception of risk was particularly influential. In those initially accepting of the vaccine, experience of a perceived immunization reaction made them feel that the risk of becoming ill from the vaccine was far greater than that of influenza (Theme b). In contrast, for those who initially refused the vaccination, the sudden awareness of an increased risk as a result of themselves or a close friend/relative becoming ill with influenza was a key factor in the subsequent acceptance of the vaccine.
...Dr B said to me ‘will you have a vacc done?’ going back ages and I said ‘I’ve never had the flu’, dead cocky. So you know what happened? I thought I was dying, I got the flu so bad that year, they had to send for Dr B. He had to come out. Ever since then I’ve had a flu vacc. [Refuser who became an Acceptor]
...and then I had a very bad go with this lot [his chest], 2 years ago, and I didn’t have the injection, and I was in East Africa, 2 years, ago just after I had this flu and with my friend and a couple of elderly people...and they [the elderly people] told me that they had had the most wonderful results from having had injections, so I had the injection last year...and I intend having them in the future. [Refuser who became an Acceptor]
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Discussion |
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Previous research into influenza vaccine uptake in the elderly has listed reasons for non-compliance and acceptance. Subjective reasoning behind decision making has previously received less attention. This qualitative study adds valuable information into how decisions are reached and highlights areas that may be subject to change. This study has its limitations in that it was conducted in one practice situated in a deprived inner city area of Manchester, and the patients interviewed were those aged 75 years and older who first language was English. Further studies are needed to confirm whether these themes are evident in the elderly (age 65 and over) residing in different types of locality and in the elderly from differing ethnic backgrounds.
The personal accounts in this study indicated that elderly people were well informed about and adopted a number of means of maintaining a healthy lifestyle, and were aware of the transmission and prevention of influenza. The decision-making process for influenza vaccination uptake is complex, and is informed by the experience of influenza and health and illness behaviours adopted and internalized at different points in the life course. Three specific influences, i.e. trust or mistrust in modern medicine, prior experience of vaccination and perceived risk from influenza, were identified as having the most salience for decision making about vaccine uptake. In this study, all respondents were aware of the statutory advice to have the influenza vaccine, but for those ‘refusers’ who were mistrustful of modern medicine, this advice year in, year out was insufficient to ‘persuade’ them to change their minds. For these individuals, the lay experiences of perceived side-effects and lack of efficacy of vaccinations combined with a lack of perceived risk from influenza remain powerful reasons to refuse vaccination. For these people, the perceived risk from the vaccination outweighed any potential benefits. The data from the individuals who changed their minds show that newly acquired lay experience and personal perceived risk from influenza were more important catalysts for change than professional recommendation or advertising by official government health agencies.
The current style of health promotion for influenza vaccination was viewed in the study as dictatorial and irrelevant by the very people it is trying to convert. Clearly, if influenza vaccination is to be a central tenet in the health promotion strategy for older people and for reducing winter pressures within the NHS, a different dimension needs to be added to existing strategies designed to promote uptake. In particular, older peoples’ own subjective assessments, understandings and experience need to be taken into consideration. In addition to the importance of the trust and credibility of advice from professional sources, and the contemporary assessment of risk and vulnerability benefits of influenza vaccine, peoples reference to earlier personal and familial life experiences of having and preventing influenza are important considerations in their acceptance and rejection of the vaccine. In terms of health promotion policy and health professionals seeking to persuade or engage people in discussion about vaccination uptake, recognizing peoples’ familial and personal experience is relevant. This is in keeping with the increasing recognition of a patient-centred philosophy as good practice in primary care settings. Thus an exploration of the disease and illness experience from the patients’ perspective, which is seen as central to the diagnosis, and management of illness might usefully be extended to consultations about vaccination uptake. Given the strong ownership of actions that promote or inhibit the maintenance of health evident in respondents’ accounts, it seems important to place the issue of influenza vaccination in a wider discussion with patients about the way in which elderly people seek to promote and maintain their health more generally. Such recognition is likely to provide valuable opportunities for promoting uptake, and maintaining congruence between lay and official constructs of preventing influenza.
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Acknowledgements |
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This study was carried out by R. T. as part of a 4-year part-time MSc in Primary Care at the University of Manchester funded by an extended study leave grant from the Department of Health. We are particularly grateful to the patients who agreed to be interviewed, and to colleagues at the Robert Darbishire Practice and the School of Primary Care, University of Manchester for their support. Thanks to Professor Martin Roland for his encouragement and his comments on the paper.
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References |
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Received on July 18, 2002; accepted on November 20, 2002
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