According to the World Health Organization (WHO) there is overwhelming evidence showing the benefits of immunization portraying it as one of the most successful and cost-effective health interventions known. Immunization achieved the eradication of smallpox in the 70s, characterized as “one of humanity’s greatest triumphs”. Vaccines have saved countless lives, lowered the global incidence of polio by 99 percent and reduced illness, disability and death from diphtheria, tetanus, whooping cough, measles, Haemophilus influenzae type b disease, and epidemic meningococcal A meningitis.

Despite these achievements vaccine-preventable diseases (VPDs) continue to threaten humanity in both developing and developed countries. Various outbreaks of infectious diseases have recently appeared even in the European region which has traditionally had high immunization coverage. For example measles, rubella and pertussis outbreaks in Europe show that risks are still high and very real (ECDC, 2013).

According to WHO immunization coverage rates in the European Region are not high enough to ensure herd immunity and halt the spread of VPDs in the Region. In some countries with previously high coverage rates have now fallen well below the 95% WHO-recommended threshold. Overall, in the Region, an estimated 700.000–1.000 000 infants born each year (2012 estimate) do not receive all of the scheduled vaccinations.

Health Care Workers (HCWs) need to be able to serve as an accurate information source for their patients and communities, as they are important role models and trusted sources of advice.

Pathogens transmitted via blood or infectious droplets, are known health and occupational risks for HCWs, many of which have died while caring for patients. However, as professionals HCWs are also at increased risk of contracting VPDs.

Immunization of HCWs is extremely important not only for the protection of patients but equally important for the protection of professionals themselves and their families. Research shows that immunization is the most important measure against employee absenteeism which may prove to be a major organizational problem especially during disease outbreaks or pandemics.

Nevertheless, despite a relevant worker protection EU directive (2000/54/EC) describing the measures to protect workers from biological agents, no significant increase in vaccination coverage is seen in HCWs. There is need to intensify efforts to achieve higher immunization rates among HCWs especially among personnel other than physicians who come into direct contact with patients such as nurses, pharmacists, social workers and other hospital based specialties.

Promoting Immunization for Health Care Professionals – HproImmune is a 3-year EU co funded project implemented by institutions from Greece, Cyprus, Poland, Lithuania, Germany and Romania; coordinated by the Institute of Preventive Medicine Environmental and Occupational Health – Prolepsis.

The project aims to provide a comprehensive educational and promotional HCW Immunization Toolkit for health professionals working in primary care and in hospitals, as well as propose recommendations for policy-makers.

For more information about the project please visit the project website – www.hproimmune.eu

The purpose of the HproImmune toolkit is to provide HCWs and hospital administrators information, tools and resources that will assist them with the planning, development, implementation, evaluation and/or improvement of immunization programs relevant in all healthcare settings. The toolkit also offers up to date information about vaccine preventable diseases as well as promotional material that can be used in relevant programs.

The toolkit will:

• Provide valuable resources and information about the importance of immunizing against VPDs
• Offer guidance on the best ways to approach health care personnel in relation to immunizations
• Provide best practice examples for the delivery of effective interventions for the promotion of immunizations among HCWs
• Provide promotional material to increase the uptake of immunizations among hospital personnel and Health Care Workers
• Provide a step by step guide on how to plan immunization programs in a hospital setting
• Share resources including policies and procedures on the immunization for VPDs

Health related human behavior is influenced by multiple factors relating to interpersonal characteristics and traits and also factors related to the social and physical environments people live in. Changing behaviors that are detrimental to health or convincing people to engage in health enhancing ones is a complex process that requires careful considerations of both interpersonal characteristics as well as social and environmental aspects. Understanding behavior and planning behavioral change activities can be guided by behavioral change theories which offer insight into the processes of change, and the effects of external influences. Theories can help identify program targets and the methods for accomplishing change, as well as outcomes for evaluation.

There are many theories and models that explain health related human behaviors. The most widely used theories in health promotion look at behavioral change from a socio ecological perspective explaining both individual but also environmental determinants of behavior.

The process of getting people to actually engage in health enhancing behaviors does not only involve raising awareness or informing about this behavior. It also requires building supporting environments and creating conditions in which people will find it easy and rewarding to engage in the specific behavior. In addition it involves addressing the multiple determinants of health behavior, which most times are beyond the responsibility of individual people.

People’s behavior is affected by what they know and how they think about various issues. Influencing what they know by providing valid and up to date information will affect to some extent how they think and act. Nevertheless, although knowledge is necessary, research has shown that it is not sufficient to produce behavioral change. People are directly influenced by their surroundings (ecology) thus intervening on the immediate and wider environment is important in bringing about change.

In addition people may be at different stages of behavioral change. Some may be open to change but may be hesitant or postpone action because of organizational barriers for example – lack of time, lack of insurance coverage. Others may not feel susceptible to diseases (risk perception) or may fear side effects or may have false information about the benefits or effectiveness of a vaccine for example.

Successful interventions need to address multiple determinants of behavior including personal/individual determinants, as well as environmental and organizational ones.

There are many theories of behavioral change used by scientists to guide behavioral change.

Some valuable resources can be found below:

1. National Cancer Institute. Theory at a glance: Application to health promotion and health behaviour, 2nd ed. United States Department of Health and Human Services, National Institutes of Health, 2005. Available from http://www.cancer.gov/cancertopics/cancerlibrary/theory.pdf

2. World Health Organisation, regional Office for Europe. The Guide to Tailoring Immunization programs - http://www.euro.who.int/__data/assets/pdf_file/0003/187347/The-Guide-to-Tailoring-Immunization-Programmes-TIP.pdf

3. The Behavioral change wheel http://www.ecdc.europa.eu/en/press/events/Documents/1110_Susan%20Michie_Part%201.pdf

The immunization of HCWs is indeed an important aspect for all health care settings, as discussed in the introduction section. The HproImmune project is advocating that Seasonal Influenza, Hepatitis B, MMR, Td/Tdap and Varicella constitute the 5 most important vaccines to protect HCWs with clinical work.

A hospital manager, infection control committee or other public health (PH) stakeholder needs to have a clear idea about the immunization needs of the hospital staff in the particular setting. In other words prior to planning an immunization program for the hospital setting or other similar intervention, a needs assessment has to be performed to guide the goals and objectives, as well as the activities, messages and materials to be used in the program.

In order to design a successful intervention at the hospital setting, planners should take into consideration:

• the literature on immunization barriers and enablers for HCWs
• literature and reports on best practices of interventions
• the national and EU legislation relating to HCW immunization
• the reported vaccination coverage of HCWs in the particular country.

The HProImmune website www.hproimmune.eu includes information on the literature concerning immunizations among HCWs, complemented with an on-line database providing information about existing guidance and related legislation in the European Union member states.

1. A necessary initial step is to determine existing immunization rates among personnel. In other words it is necessary to know who is vaccinated and for which VPDs in order to set clear targets and objectives of what needs to be achieved.

A good way to determine existing vaccination coverage of HCPs in a facility is through a questionnaire, which at the same time can also capture the barriers as well as enablers towards immunization of staff.

The HproImmune project developed a questionnaire to explore vaccination coverage of HCWs in Europe, as well as related behavior. This questionnaire can be used in a hospital setting as well and is available from the project website at www.hproimmune.eu/index.php/hproimmune/survey

Other ways to determine vaccination coverage is to review existing information from national sources such as the local or national public health department or institute.

2. Subsequently it is necessary to acquire an understanding about vaccine related behavior among the HCWs in the particular hospital, in other words try to identify what affects related behavior both in a negative and in a positive way. This means identifying barriers and enablers which may be financial, social or environmental. This is an important step for planning activities and selecting the focus and messages of your campaign.

A questionnaire such as the one used in the Hproimmune project will yield information about the barriers and enablers of vaccine related behavior in the particular setting (www.hproimmune.eu/index.php/hproimmune/survey ).

In this process it is also necessary to listen to HCWs and involve them, e.g. through qualitative methods such as focus groups. The methodology and results of focus groups undertaken in the framework of the HproImmune consortium are available from the HproImmune website www.hproimmune.eu

Our research showed that:

Health Care Workers are willing to become immunized, if they:
• believe in vaccine protection;
• are concerned about their patients and their families;
• have easy access to vaccines;
• vaccines are provided free of charge.

Health Care Workers do NOT want to become immunized, if:
• they are concerned about side effects and long-term effects of the vaccine;
• they doubt vaccine effectiveness;
• their perception of the risk of VPDs is low, for example in the case of seasonal influenza,
• their insurance scheme does not cover associated costs.

Health Care Workers in our research asked:
• for a clear institutional immunization policy – look at the model policy in this toolkit
• not to focus only on immunization, but also address other health and work safety problems
• not to focus only on providing information on immunization against seasonal influenza but include other vaccines as well
• to involve occupational physicians, epidemiologists and/or infection control personnel in the hospital setting on a regular basis.

The product of this step will be an individualized needs assessment report for your setting, which will summarize the baseline situation as regards vaccination coverage of your target group of HCWs and their basic barriers and enablers towards immunizations. This will provide you with the starting point, as well as the basis for the evaluation of your intervention.

Once the facts about the target groups are known and needs are determined, it is time to define what the program aims to do, in other words it’s time to set goals and objectives. These should relate directly to the interventions that will be implemented and to what will be the expected outcome that will be evaluated so as to determine the effect and success of the action. It is thus imperative that goals and objectives are very clearly chosen and carefully worded.

A goal is a general statement setting the program’s direction and overall intent. It is what the program ultimately wants to achieve, it is the end result of a program.

An ultimate goal is achieved through a series of action steps. These action steps are referred to as objectives. Objectives describe the changes that the program wants to bring in order to attain the overall goal.

Objectives are differentiated between Process Objectives and Effect/Outcome Objectives. Process objectives are related to the method followed in order to achieve outcomes. A simple way of thinking about process objectives is to focus on what are we doing and how, in other words the products of the program, the resources, the activities, the outputs.

Effect/Outcome Objectives refer to the benefits or changes that program participants or target audience will experience as a result of the program activities. An effect/outcome is who will have received/achieved what benefit or change in what amount within what period of time.

A good way to ensure that project objectives include all the necessary action steps of a program is to follow the SMART rule:

• Specific – What do you want to achieve, by when, for who, where and how much do you want to achieve?
• Measurable – Can you measure the change?
• Achievable – Is the objective reached with a reasonable amount of effort?
• Realistic – Is it realistically possible using the skills and resources available?
• Time limited – Can it be reached in a realistic time?

A project plan should have a number of objectives and sub objectives in order to cover all planned activities. An example of project goals, objectives and strategy objectives is shown below:

Project Goal: To decrease morbidity from Hepatitis B among hospital staff

Effect/outcome Objective

• To increase Hepatitis B vaccination by 30% among HCWs of Hospital X, who are not fully immunized, by the end of 2014

Process objectives

• Project staff to investigate baseline rates for Hepatitis B immunization by month 1 following the project kick off
• Hospital management to develop a hospital employee policy on immunizations and distribute it to HCWs by month 2 following the project kick off
• Develop educational material such as fact sheets on Hepatitis B vaccine for the various categories of HCWs taking into consideration the findings from the HProImmune survey questionnaire, by month 5 following the project kick off
• Distribute Hepatitis B fact sheets to all HCWs by month 6 following the project kick off
• Organize educational presentations about Hepatitis B for all nursing staff by the end of spring 2014. Sessions should include no more than 50 nursing staff at a time
• Provide nursing staff free of charge immunization for Hepatitis B within the hospital once every month
• Keep detailed personal immunization records for all nursing staff

Designing appropriate activities
Choosing messages
Determining materials

Remember: Take into consideration barriers and enablers

Once goals and objectives are determined it’s time to plan activities, choose the means of delivery and the content of the material used as well as dissemination messages.

Knowing the behavioral barriers and enablers of the target group from the needs assessment is valuable for designing the content of the project activities.

HProImmune research showed that the various categories of HCWs do perceive immunizations differently and there are different needs in terms of information and educational material.

More physicians believe that vaccines are important for reducing or eliminating serious diseases (96.3%) as opposed to 81% for nurses and 83.1% for other allied personnel. Around 7.6% of nurses and 4.2% of allied personnel do not believe in vaccinations or are not certain about their usefulness.

Our research showed that HCWs are skeptical about specific vaccines for example influenza.

For a full report on our survey results visit the project website www.hproimmune.eu

HCWs can benefit from up to date scientific knowledge about immunizations. Apart from addressing possible knowledge gaps scientific information should address misunderstandings and current rumors and myths.

Medical personnel know their facts and require more detailed scientific up to date information. They are not easily convinced by over exaggerations and simplifications. Nursing and allied health professionals on the other hand have gaps of knowledge, especially as regards vaccines other than seasonal influenza. They require sound information in a more simplified way, and answers to popular rumors and myths surrounding the use of particular vaccines. Basic principles to take into account when designing the information material:

• Inform about the effectiveness, side effects and long term effects of vaccines using trustworthy, up to date information
• Include information on the diseases and their risks vs. the risks of each vaccine
• Openly address doubts and misinformation about vaccines
• Don’t overestimate the effectiveness of a vaccine when the science to back this up is not available.
• Address the truths and myths for each vaccine separately

Read the fact sheets addressing the 5 recommended vaccines for all HCWs that were developed by the HproImmune team for this toolkit.
(get them from the download area)

Evidence from the literature shows that the most effective immunization programs addressing HCWs used a variety of methods including awareness raising, educational activities while also addressing hospital policy and hierarchy commitment as well as practical aspects involved in the delivery of immunizations.

A complete list of promising interventions as assessed by the HproImmune project can be found on the project website www.hproimmune.eu in the report on Best Practices. Some of the most important enablers that emerged from the HProImmune research were practical, such as easy access to vaccines. Thus when planning for an intervention to promote immunization among employees at a hospital one must consider practical aspects for example:

• Make immunizations free of charge
• Organize on site delivery and offer flexible times for immunization accessible to all shifts.

The following have also proved very important for delivering successful immunization initiatives in health care settings:

• Sending reminders – Look at draft invitation letter in the download area
• Immunization calendar/scheduler - see example in the download area
• Offer incentives
  • Days/hours off
  • Promotional material – pens, pins, stickers, screen savers – see some examples in the download area
• Repeat campaigns regularly
• Address new comers and medicine students, nursing and other health professionals

It is important to use the right messages depending on the group of employees you are targeting:

• Emphasize the importance of HCWs as role models who are highly respected in the community.
• Emphasize the fact that immunizing HCWs is the most effective way of protecting against absenteeism especially during periods of high demand
• Give the good example by getting yourself and your immediate team immunized and let your employees know it.
• Emphasize the protective nature of immunizations
• Tailor information material and messages to each target group - nurses and other non-medical personnel may need different type of information and different approach methods. Doctors may need more scientific information and access to articles, systematic review, research – see the list of resources in this toolkit and visit the project website for more information
• Immunization is not the only health and safety issue of importance to HCWs. Incorporate immunization within a general health and safety framework and address other aspects as well. Show an overall consideration of health and safety issues of your personnel.
• Make the consequences of not vaccinating known: Campaigns that included mandatory elements (such as declination forms or obligation to wear masks for unvaccinated workers) resulted in an increase in vaccine usage in hospital settings – see an example of a declination form in the download area

Evaluation is an ongoing process that helps to determine whether or not the program has met its predefined goals and objectives. Success should concern both the process as well as the project outcomes. The chosen indicators should correspond to each one of the process and outcome objectives and be measured in parallel with the implementation of the objectives.

Indicators have to be chosen and developed for both the process objectives as well as the effect/outcome objectives.

Process evaluation is conducted during the project, and aims at monitoring the implementation process, improve the work in progress and increase the likelihood that the project will be successful. The indicators need to be linked to the planning and organization of the project activities, focusing on whether the activities are implemented according to plan, how obstacles and difficulties will be identified during the implementation and dealt with, and how the quality of the project implementation will be assured.

Outcome/impact evaluation is usually performed towards the end of the project or after an agreed period, if long term effects are measured, and aims to verify if the project objectives have been achieved. The indicators should be linked to the effect/outcome objectives, and verify if the stated objectives have been achieved.

Once evaluation questions have been formulated and indicators specified, it is valuable to determine the methods for the collection through which data for the evaluation will be collected. Methods must be specified for each evaluation question. These methods can be quantitative – questionnaires and surveys, or qualitative – interviews, focus groups.

In order to adequately evaluate a hospital based immunization program it would be very useful to establish right from the beginning an electronic record of monitoring immunizations as well as a system for Vaccine Safety Monitoring.

Download an example of a comprehensive evaluation plan here

Download an example of a planning checklist that can offer guidance to hospital management implementing vaccination programs in a hospital setting and can facilitate evaluation.

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