BACKGROUND/RATIONALE:
Individuals with spinal cord injuries and disorders (SCI/D) are at high risk for respiratory complications from influenza. Health care workers (HCW) can spread influenza virus in health care settings and are professionally responsible for receiving annual influenza vaccination. Vaccine rates for SCI/D HCWs have been about 50% for multiple years. Influenza declination form programs (DFP) have been successful in other HCW cohorts and may help VA achieve a targeted rate of 90% by 2020.

OBJECTIVE(S):
To pilot test a DFP in VA SCI/D HCWs. Specific aims were to: (1) conduct a formative evaluation of the implementation process and DFP adoption; (2) assess the impact of a DFP on SCI/D HCW influenza vaccination; and (3) assess costs of DFP implementation.

METHODS:
Mixed methods approach evaluating processes and outcomes of DFP implementation. A facilitation workgroup comprised of our research team, operations partners, and local leadership identified local implementation team members and developed facility-tailored implementation plans (e.g., decided on content and format of declination forms). Regular phone calls tracked implementation progress, barriers/facilitators, and best practices. Information on other influenza vaccine promotion strategies was collected at pilot sites with a tracking form. Post-implementation interviews with 3-4 key informants per pilot site provided insight into what influenced implementation. Self-reported vaccination rates were obtained by a mailed HCW survey at 2-pilot and 2-matched control SCI sites. Cost data (staff time and resources associated with program activities) were obtained from the tracking form and supplemented with interview data.

FINDINGS/RESULTS:
Using DIM and PARiHS constructs, findings show the DFP has relative advantage because it provides an education opportunity and systematically tracks declination reasons; "If some people put they are scared of needles [on the form] . I can say 'hey, look how small the needle we use is.' It lets me talk to people in a more . focused way to directly address their concerns."(S2)
DFP was compatible with unit culture; "employees were reminding each other [to fill it out] . they are a very cohesive group" (S1) and it was easy to use (complexity), "I didn't have any problems. I just [asked] 'hey did you fill out my form?' It's yes or no, there was no confusion." (S2) A major facilitator for DFP implementation (observability) was leadership support (context), "The service chiefs in the area and the nurse managers were very proactive, support from management was very good." (S1)
Respondents appreciated the opportunity to "try out" the intervention (trialability). An unforeseen advantage was also noted: DFP provided a better way to record who the vaccine had previously been offered to, "I know if they are on my list and declined before, so I do not need to ask them again when I make rounds." (S1) However, they noted one barrier in particular: difficulty reaching employees on non-traditional shifts, "I am not sure if there is a way to tackle all shifts (nights, weekends), but maybe more people need to be involved, like the infection control facilitators." (S2)
On the tracking form, we asked local leaders about 20 common hospital-level influenza vaccine promotion strategies (e.g., mobile flu cart, cost-free, after-hours availability, email reminders). Site 1 had fewer activities than site 2 (75% vs. 85%). Sites were similar in types of strategies utilized, except for providing "easy access" to vaccine (site 1 noted having 57.1% of the activities vs. 87.5% at site 2).
Overall, the DFP was: well-accepted (compatible), flexible (trialability), easy to use/complete (complexity), and supported by leadership (observability). At site 1, DFP implementation was complete in under 2 months. Using an existing vaccination program, the 'mobile flu cart,' to incorporate the DFP, within nine 1-hour visits, 100% of declination forms were completed. Site 2 completed 48.8% of forms in six 1-hour visits, using a vaccination table on "all staff" meeting days, set up outside of the meeting room. Leadership at site 1 supported dedicated infection prevention staff time to execute the DFP and both infection control and SCI Center Chiefs were highly visible and actively championed DFP participation.
Surveys were distributed to 261 HCWs across the 2 implementation and 2 control sites. Completed surveys were available for 74 HCWs (28.35% response rate). At implementation sites, post-implementation self-reported HCW vaccination rates were significantly higher than pre-implementation rates (77.4% vs. 53.5%, p=0.01). Control site vaccination rates also increased from pre to post-time periods (57.1% vs. 83.7%, p=0.002). Future examination is needed to understand assess DFP effectiveness (alone and with other initiatives) at a larger number of sites (larger HCW sample). Cost findings suggest additional staff time was needed to administer forms and track completion, but time and resources required were minimal. At site 1, total staff time was 42.5 hours (over 2-months) and 26.5 hours at site 2 (over 4.5 months). Average cost of total staff time was $2,093 per site.

IMPACT:
Strong support from operations partners and local leadership is essential in planning/start-up stages. A facility-tailored plan and local implementation teams were key. Findings showed a significant increase in HCW influenza vaccination post-implementation, suggesting that DFPs are a valuable influenza vaccination promotion strategy (used alone or with existing promotion campaigns). Capitalizing on existing strategies to promote vaccination facilitates implementation (trialability), and visible local leadership support (context) facilitates buy-in and staff participation. HCW DFP participation varied by site; this was likely a direct reflection of levels of local leadership support. Our survey also asked if HCWs would support a DFP at their site which required them to sign for declination and provide a reason for vaccine non-receipt; pilot site data showed an increase from 48% support (pre-) to 69% (post-implementation), suggesting that many HCWs embraced the DFP after implementation.
This study provides pilot data on DFP implementation feasibility and an idea of what facilitated this process at VA SCI centers; based on findings we believe a national roll-out of DFPs is feasible and recommended in VA. However, a larger study is needed to identify necessary and sufficient components of the DFP that should be in place for a successful program, as sites tailor the strategies to meet their facility needs.

---

External Links for this Project

NIH Reporter

Grant Number: I21HX001212-01
Link: https://reporter.nih.gov/project-details/8542138

---

PUBLICATIONS:

Journal Articles

1. LaVela SL, Etingen B, Miskevics S. Attitudes toward influenza vaccination improvement strategies in Veterans Affairs health care workers providing care for patients with spinal cord injuries and disorders: Acceptability of a declination form program. Vaccine. 2015 Aug 26; 33(36):4602-9. [view]
2. LaVela SL, Hill JN, Smith BM, Evans CT, Goldstein B, Martinello R. Healthcare worker influenza declination form program. American journal of infection control. 2015 Jun 1; 43(6):624-8. [view]
3. Hill JN, Smith BM, Evans CT, Anaya H, Goldstein B, LaVela SL. Implementing a declination form programme to improve influenza vaccine uptake by staff in Department of Veterans Affairs spinal cord injury centres: a pilot study. The Journal of hospital infection. 2015 Oct 1; 91(2):158-65. [view]

Conference Presentations

1. LaVela SL, Hill JN, Smith BM, Evans (Mayfield) CT, Goldstein B, Martinello R. Healthcare Worker Influenza Declination Form Program. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA. [view]
2. Hill JN, Smith BM, Baracco G, James S, Salazar-Pendlebury A, Martinez-Arizala A, Szum P, LaVela SL. Implementation and Formative Evaluation of an Influenza Vaccination Declination Form Program to improve Staff Vaccination: Pilot study in Veterans Affairs Spinal Cord Injury Units. Poster session presented at: AcademyHealth Annual Research Meeting; 2014 Jun 10; San Diego, CA. [view]
3. Hill JN, LaVela SL. Implementing an Evidence-Based Strategy to Promote Influenza Vaccination. Paper presented at: Summer Institutes on Quality Improvement Annual Meeting; 2013 Jul 11; San Antonio, TX. [view]
4. LaVela SL, Hill JN, Smith BM, Evans (Mayfield) CT, Anaya H, Goldstein B. Use of the Diffusion of Innovation Model to Evaluate Implementation of an Evidence-Based Practice to Promote Influenza Vaccination in SCI/D HCWs. Poster session presented at: National Institutes of Health / AcademyHealth Conference on the Science of Dissemination and Implementation; 2014 Dec 8; Bethesda, MD. [view]

DRA: Brain and Spinal Cord Injuries and Disorders, Infectious Diseases
DRE: Prevention
Keywords: none
MeSH Terms: none