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Discussion
Influenza vaccination coverage in patients aged ≥ 65 years varied widely, but was within the ranges found by other studies in Spain and Europe, and was associated with the vaccination of their primary care physician, after controlling for the possible effects of physicians knowledge, opinions and attitudes towards influenza. Likewise, vaccination of primary care physicians (55.3%) was higher than that found in other Spanish and international studies.
Both vaccine coverages were far from the European targets for HCW and the elderly and may have been overestimated due to a possible bias caused by a greater response to the survey from physicians with a better vaccination record. We compared the characteristics of early and late responders to the survey as a proxy for non-responders: no differences were found according to age and sex, but influenza vaccine coverage in patients aged ≥ 65 years was higher for physicians who were early responders (Additional file 1: Table S1 http://www.biomedcentral.com/1471-2296/16/44/additional).
The vaccine influenza coverage in patients aged ≥ 65 years was quite similar to the figures of the Spanish Health Ministry, but the coverage in regions participating in the study was slightly higher than in the remaining Spanish regions (Additional file 1: Table S2 http://www.biomedcentral.com/1471-2296/16/44/additional).
The highest reported European vaccination coverages in patients aged ≥ 65 years are in the Netherlands and some parts of the UK (England, Northern Ireland and Scotland), which reached or almost reached the EU 2014/15 target. Five countries (France, Germany, Ireland, Italy and Spain) reported vaccination coverages of around 60% for this specific age group. Denmark, Finland, Luxembourg, Malta, Norway, Portugal and Sweden reported vaccination coverages of around 50%. The remaining countries were below 50%.
The study had some other limitations. The response rate of primary care physicians was low, although similar to that of other studies conducted using web-based questionnaires. As the questionnaire was self-reported, it was not possible to validate the questions or use interviewers to clarify any disputed points. However, the questionnaire was adapted to the Spanish health system according to a questionnaire used in another study. In addition, a pilot study was carried out. Information on vaccination coverage was collected from the records of healthcare providers for all patients ascribed to each physician in the form of clusters and, therefore, the estimate was not controlled according to the individual variables of each vaccinated patient.
The results of the study provide some relevant information. The effect of vaccination of the primary care physician was a minor determinant of the vaccination coverage of their patients aged ≥ 65 years (57.3% versus 55.2%), but remained statistically-significant after controlling for other potential effects associated with the physician's knowledge, attitudes and beliefs on influenza vaccination. The 2% increase in coverage, although moderate, should be considered positively, as it relates to physicians in direct contact with the majority of the population. In addition, the advantage conferred by being associated with an intervention (vaccination of physicians) that may reduce the transmission of influenza to vulnerable patients and possibly increase the physician's confidence in providing counseling on vaccination, should be taken into account. Some studies suggest that medical advice has greater efficacy if it comes from vaccinated physicians.
Vaccination of patients aged ≥ 65 years was also associated in the multilevel regression model with physicians having a favorable opinion of vaccine effectiveness. This variable has been associated with improved vaccination coverage in other studies and should be taken into account in educational programs aimed at primary care physicians whose objective is to improve vaccination coverages. However, vaccination of patients was not associated with a higher level of knowledge of their physicians provided by training activities. Therefore, any intervention programs aimed at Spanish primary care Spain should be directed towards improving opinions and attitudes about vaccination rather than trying to increase knowledge.
Interventions to increase influenza vaccination rates in HCW have shown small effects on vaccination behavior, and their long-term success is unknown. Kok et al. suggested that a systematic approach (i.e. intervention mapping) is needed for the successful development and implementation of programs to promote influenza vaccination in HCW, identifying sociocognitive variables that drive the recommended behavior. Other studies show that having a mandatory vaccination policy is the strongest predictor of vaccine coverages in HCW and that implementing such a policy should be a priority for all healthcare agencies. In the absence of or in conjunction with a mandatory vaccination policy, other interventions may be implemented to increase vaccination compliance in HCW. These include reducing barriers to vaccination, encouraging staff to be vaccinated, and introducing educational campaigns, all of which suggest the need for healthcare administrators to be active in encouraging vaccination in HCW. Healthcare agencies should provide free vaccination on site to their staff whenever possible to increase compliance. This is even more critical in nonhospital settings. Educational campaigns based on beliefs aligned with scientific evidence and more favorable attitudes toward vaccines can also improve the intent of HCW to be vaccinated.
There is sufficient evidence that increases in the vaccination of people aged ≥ 65 years leads to a reduction in mortality and morbidity in both institutionalized and community-dwelling patients. In addition, clinical trials show it is feasible to increase the vaccination of primary care physicians. A clinical trial by Abramson et al. found that vaccination coverage in the intervention group was 52.8% compared with 26.5% in the control group. However, unlike in our study, these authors did not show that this increase in the vaccination of physicians led to increased vaccination of their patients.
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