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The American Journal of Managed Care December 2012
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Impact of Education Program on Influenza Vaccination Rates in Spain
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Impact of Education Program on Influenza Vaccination Rates in Spain

Bernardino Roca, PhD; Elena Herrero, PhD; Elena Resino, MD; Vilma Torres, MD; Maria Penades, MD; and Carlos Andreu, PhD
A simple education program was effective in improving the influenza vaccination rate, although vaccination in the previous year was the main predictor of adherence.
Objectives: To assess the impact of a simple education program on adherence to influenza vaccination.

Study Design: Randomized open controlled study.

Methods: The education program group (EPG) received an education program via surface mail, consisting of information regarding the effectiveness and safety of the influenza vaccine. The no-program group (NPG) received no intervention. All patients in 13 primary care practices in the city of Castellón, Spain, were included if they were 60 years or older on the first day of the 2009 seasonal influenza vaccination campaign.

Results: There were a total of 2402 participants (mean age 70.4 [± 7.1] years); 1338 (55.7%) were women. In 2009, 950 participants (39.5%) received the vaccine, including 900 of the same participants (37.5%) who had received it in 2008 (P = .14). Of those vaccinated in 2009, 501 (52.7%) belonged to the EPG and 449 (47.3%) to the NPG (P = .01). In a logistic regression analysis we found an association between adherence to vaccination in 2009 and both vaccination in the previous year and receiving the educational intervention. Influenza-related morbidity was similar in both groups during the 7 months after vaccination.

Conclusions: A mailed reminder program was effective to improve influenza vaccination rate, but only to a limited extent. Vaccination the previous year was the main predictor of adherence to vaccination. More programs are needed to improve vaccination rates in the study community.

(Am J Manag Care. 2012;18(12):e446-e452)
An education program delivered via surface mail was effective in improving the influenza vaccination rate in Castellón, Spain.

  • The education program consisted simply of information regarding the effectiveness and safety of the influenza vaccine.

  • Among individuals vaccinated in 2009, 501 (52.7%) received the educational intervention and 449 (47.3%) did not (P = .01).

  • However, vaccination in the previous year was the main predictor of adherence to vaccination.
Influenza is a highly contagious infection that causes outbreaks and epidemics throughout the world, generally during the winter season. Every year the disease is responsible for thousands of deaths and substantial costs for health systems worldwide. Although rates of influenza are highest among children, serious illness and death are particularly common in patients with chronic medical conditions and in older individuals, as both groups are especially vulnerable to complications of the disease.1,2

Influenza vaccination of seniors has been found to be effective in reducing hospitalization for heart disease, cerebrovascular disease, pneumonia, and influenza, and also in reducing overall risk of death.3,4 Despite those benefits, signif´╗┐icant proportions of patients for whom the vaccine is recommended fail to receive it. In recent years, vaccination rates have progressively increased in most developed countries, but efforts to improve the rates are still pressingly needed.5

Strategies to improve vaccination rates can be classified into 4 different categories: (1) personalized education programs, communicated via letters, phone calls, or other means, designed to increase perceptions of susceptibility to influenza, vaccine effectiveness, and vaccine safety; (2) enhancement of access to vaccination, for example by providing more clinics and better hours, vaccinating during home visits, offering free vaccine, and decreasing administrative barriers to vaccination; (3) interventions to ensure that healthcare workers have adequate information about influenza and the vaccine, as well as strategies to increase these workers’ motivation and willingness to vaccinate patients; and (4) social intervention, including administrative frameworks and campaigns to inform the population about influenza and vaccination, implementation of policies that suggest changing from risk-based to age-based vaccination targeting, remuneration of healthcare workers for increasing vaccination rates or achieving targets, and so forth.6

Studies assessing those strategies are scant, and most of them have been carried out in the United States.6,7 So many uncertainties remain regarding the efficacy of those strategies, especially in countries with healthcare systems different from the US system. We undertook this study to assess (1) the impact of a simple education program on the rate of adherence to seasonal influenza vaccination, (2) the morbidity experienced by patients during the 7 months after vaccination, and (3) the factors associated with adherence with seasonal influenza vaccination.


This was a randomized open controlled study to assess the efficacy of an education program designed to improve the rate of seasonal influenza vaccination in patients 60 years and older.

The study was done in Centro de Salud Rafalafena, a health center situated in the city of Castellón, Comunidad Valenciana, Spain, associated with the Agencia Valenciana de Salud of the National Health Service. Participants belonged to the practices of 13 family physicians. All patients in those practices were included if they were 60 years or older on the first day of the 2009 seasonal influenza vaccination campaign (ie, September 28, 2009). Patients were excluded if they had an egg allergy or had been diagnosed with Guillain-Barré syndrome within 6 weeks of influenza vaccination in previous years. Participants were included and excluded with the help of Abucasis II, the intranet application used by the Agencia Valenciana de Salud for clinical follow-up of all of its patients.8 We used a computer random-number generator and a 1:1 ratio to randomly assign participants to 1 of 2 groups: the education program group (EPG) or the no-program group (NPG). The study was open for participants but blinded for the healthcare workers responsible for caring for the patients.

The program was delivered to participants by means of a personalized letter sent via surface mail in the first days of September 2009, a few weeks before initiation of the official seasonal influenza vaccine campaign. Postal addresses were obtained from Abucasis II, where patient data are permanently updated in order to provide medical assistance. The letter was written in Spanish on a DIN A4 sheet of paper and included basic information about the clinical manifestations and possible complications of influenza, and about the efficacy of the vaccine to prevent the disease, according to recommendations of the Centers for Disease Control and Prevention9 and the local authorities of the Comunidad Valenciana.10 The content and style of the mailing were intended for patients. The letter addressed common concerns about the flu shot and was written in easy-to-understand language. The mailing was sent once to eligible participants.

For every participant, the following variables were obtained: sex, age on the day of initiation of the 2009 seasonal influenza vaccination campaign, nationality, race, labor status (worker or retired), code of the primary care physician responsible for medical attention, district or town of residence, seasonal influenza vaccine received in 2009 or not, week of the campaign when the vaccine was received, seasonal influenza vaccine received in 2008 or not, visit to the Department of Health hospital emergency department after initiation of the 2009 seasonal influenza vaccination campaign or not, admission to the Department of Health hospital after initiation of the 2009 seasonal influenza vaccination campaign or not, reason for the visit to the emergency department (respiratory disease, heart disease, cardiovascular disease other than heart disease, other nonsurgical disease, surgical disease, or other reason), and reason for admission (respiratory disease, heart disease, cardiovascular disease other than heart disease, other nonsurgical disease, surgical disease, other reason).

Variables related to personal data or vaccination were recovered from Abucasis II, and variables related to visits to the emergency department or admissions to the Department of Health hospital were recovered from the center general database, where visits and admissions are coded according to the International Classification of Diseases, Ninth Edition, Clinical Modification.

No variables related to pandemic influenza, which also occurred in 2009, are included in our study.11

The study was carried out according to the good clinical practice principles set out in the Declaration of Helsinki in 1964 and subsequent updates.12 The study was approved by the Clinical Research Committee of the Department of Health of Castellón, Spain. Participants’ identifying details were replaced by codes, which were used throughout all phases of the study.

On the basis of the percentage of participants vaccinated in 2008 and results of previous studies,6 we calculated that a sample size of 1187 participants in each group was needed to find a vaccination rate difference of at least 5% between the EPG and the NPG (42.5% and 37.5%, respectively), with a level of significance of P = .05 and a power of 80%. Discrete variables are reported as absolute values and frequencies, and continuous variables are reported as mean and standard deviation if normally distributed or as median and interquartile range if not normally distributed. The following bivariate analyses were used: the χ² test for discrete variables, independent samples, or repeated measures; t tests for normally distributed continuous variables; and the Mann-Whitney U test, Wilcoxon signed rank test, or Kruskal-Wallis H test for nonnormally distributed continuous variables. A multivariate logistic regression analysis was carried out to assess the possible association of the most representative variables in the study (independent variables) with getting or not getting an influenza vaccination in 2009 (dependent variable). In all analyses an alpha level of <.05 was used, 1 tailed if a unidirectional hypothesis on the results existed or 2 tailed if such hypothesis did not exist.


A total of 2402 patients were included. All data on all variables, except for labor status, were available for 2241 participants (93.0%), and the code of the primary care physician was available for 2125 participants (88.5%). None of the sent letters was returned to sender. No patients were excluded because of egg allergy or previous diagnosis of the Guillain-Barré syndrome.

A total of 1338 participants (55.7%) were women. The mean (± standard deviation) age of participants was 70.4 (±7.1) years, while their median (interquartile range) age was 69 (64-76) years. A total of 1891 participants (78.7%) were retired. Almost all participants belonged to the same sociodemographic group: 2396 (99.8%) lived in the province of Castellón, 2386 (99.3%) were Spaniards, and 2380 (99.1%) were white; most (ie, 2360 [98.2%]) lived in the city of Castellón. The main characteristics of the EPG and NPG groups are shown in Table 1; no significant differences existed between the groups with respect to those characteristics.

The proportion of participants cared for by each primary care physician (PCP) varied substantially. The physician with the largest number of participants was in charge of 268 patients (11.2%), and the physician with the smallest number was in charge of 105 patients (4.4%). A total of 277 patients (11.5%) were not assigned to any physician.

Of all the study patients, a total of 950 (39.5%) were vaccinated in 2009; 900 (37.5%) of those same patients were vaccinated in 2008 (P = .14). A total of 752 patients (31.3%) were vaccinated in both 2008 and 2009.

The Figure displays the number of patients vaccinated every week during the seasonal influenza vaccine campaign of 2009. A total of 49 patients (5.1%) received the vaccine outside the campaign period.

Table 1 shows the vaccination rates for EPG and NPG participants. The rates did not differ in 2008, but did differ in 2009, with a higher vaccination rate in EPG patients. In 2009, 41.7% of EPG participants were vaccinated compared with 37.4% of NPG participants. Vaccinations were given to 52 more EPG participants than NPG participants, for an 11.6% increase in the vaccination rate. That means that 23 education program letters must be sent to gain 1 vaccinated person. Comparison of vaccination rates in both years showed that 43 more EPG patients were vaccinated in 2009 than in 2008 (a 9.4% increase), whereas only 7 more NPG patients were vaccinated in 2009 compared with 2008 (a 1.6% increase) (P <.01).

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