Part 1. Community Guideline Update and Rationale for Intervention
| Author & Year | Intervention Setting, Description, and Comparison Group(s) | Study Population Description and Sample Size | Effect Measure (Variables) | Results, including Test Statistics and Significance | Follow-up Time |
| Ofstead et al. 2013 | Three factories within one large US manufacturing corporation. Each were similar in location, staff, and in-house clinic. Site C was the control with only the standard corporate flu program. Sites A and B included additional material and intervention, with Site A directed only at employees and Site B directed at both employees and their families. Surveys were conducted at Sites A and B in May and June of 2010 regarding knowledge and beliefs of influenza and vaccinations with a $5 gift card incentive to the first 500 participants at each site. | Approximately 6,500 factory workers split between three factories. Demographics were primarily male (~65%) and with a mean age of 45 years. | Beliefs about vaccinations, reasons for vaccination acceptance/refusal, work missed because of flu, flu-related expenses, sources of information about flu and vaccinations. | Vaccination rates among insured employees and dependents (N =13,520) increased significantly after the intervention (P < 0.001) with over 90% receiving vaccination at worksite events. Reasons for receiving vaccination were primarily economic. Knowledgewas associated with vaccination, but customized education did not changebeliefs. | Surveys to all three factories were sent one year later in May to June of 2011. |
| Nowalk et al. 2010 | Eligible companies were stratified based on 2007-2008 vaccination rate and company size. 54 sites were chozen and randomized to each of the three arms: Control, Choice, and Choice Plus, with 18 sites per arm. Control was only given injectable vaccination, Choice was given injectable and nasal, and Choice Plus was given the choice as well as increased advertising and a $5 incentive. Surveys were completed to assess employer and nurse fidelity. | 12,222 employees across 54 companies across a broad range of fields. | The primary measure of interest was the change in vaccination rate between treatments and between years. | The overall vaccination rate increased from 39% to 46%(p=0.001). Rates of injectable vaccination increased by 15.9% in the Choice Plus arm vs Control for workers aged >50 years (p=0.024) In hierarchic linear modeling analyses, factors signifıcantly associated with increasedvaccination were older age, female gender, previous company vaccination rate, and the ChoicePlus intervention. | One vaccination season |
| Shahrabani and Benzion 2010 | Shahrabani and Benzion conducted a cross-sectional study by sending a research questionnaire to 13 companies in various industries in Israel. In each industry, at least one company which does offer on-site flu vaccinations and one which does not. The questionnaire was sent out to a total of 879 workers distributed randomly among different departments. | 879 surveys sent out across 13 different companies. 616 total respondent across 13 different companies. | The questionnaire included variables like: socio-demographic info, vaccination history, intent for vaccination, motivation for vaccination/non-vaccination, and perceived probability of contracting influenza without vaccination. | Results to the survey showed significant factors affecting vaccination compliance include a vaccinationprogram at workplaces, vaccinations in the past, higher levels of vaccine’s perceivedbenefits, and lower levels of barriers to getting the vaccine. | N/A |
2. The Community Preventive Services Task Force currently recommends interventions with on-site, reduced cost, and actively promoted influenza vaccinations, based on evidence of their effectiveness in increasing influenza vaccination coverage within the worksites. Their literature review yielded 5 adequate studies, all of whose effect sizes were moderate to large. In addition, one economic study was evaluated, and it determined that savings were estimated to be $129.41 per vaccinated person, but it did not include some factors so no firm conclusion could be drawn.
After further evaluation since the original 2008 recommendation, we continue to recommend interventions with on-site, reduced cost, and actively promoted influenza vaccinations.
There are not any changes to the original recommendation. The evidence continues to be statistically significantly in favor of intervention. Both Ofstead et al. and Nowalk et al. demonstrated that a corporate intervention with increased advertising increases vaccination rates for the employees at large sample sizes, across numerous sites, and across many different non-healthcare fields. In addition, according to Ofstead’s survey, the primary reasons for receiving vaccination were economic, meaning that a reduced or no cost, convenient program at an employee’s workplace which is heavily advertised should cater directly to individual’s reason for receiving or not receiving an influenza vaccine. Shahrabani and Benzion corroborate this, with their surveys indicating increases in influenza vaccination when individuals had vaccination
program at workplaces, vaccinations in the past, higher levels of vaccine’s perceived
benefits, and lower levels of barriers to getting the vaccine.
3. The Social Cognitive Theory (SCT), one of the most common and well-researched health behavior theories, synthesizes the relationship and influences between an individual, his behavior, and his environment (NCI, 2005). In particular, SCT states that a person’s behavior is altered by three primary influencers: self-efficacy, goals, and outcome expectancies. Within the context of influenza, it makes sense that advertising the vaccine as a low-cost, on-site program will not only lower the barrier of entry of flu vaccination, but also will increase these factors if done correctly. The promotion should emphasize the effectiveness of the vaccine as well as the potential risks of getting the flu.
Part 2. Theoretical Framework and Models
4. Constructs
Reciprocal determinism: Reciprocal determinism is one of the overarching themes within SCT. It states that changes within the person, behavior, and environment alter and influence one another. With flu vaccines, this is important because changing the environment to be one which actively promotes vaccines will subsequently influence behavior change.
Behavioral capability: Behavioral capability is one’s ability to actually perform a specific behavior. Creating a low-cost, on-site vaccine greatly increases behavioral capability, because the barrier of entry is now lower, so it’s much easier to perform the behavior (get the vaccine).
Expectations: Expectations are one’s projected consequences of a behavior. While some may validly doubt the efficacy of the flu vaccine, that doesn’t change the fact that those who get the vaccine are far less likely to get the flu, and it’s important that advertising reflects that.
Self-efficacy: Self-efficacy refers to one’s perceived ability to perform some sort of behavioral change within the context of one’s environment. This ties in many of the other factors where increased advertising will increase self-efficacy because it promotes self-efficacy that one can change their likelihood of contracting flu with a simple means.
Observational learning (modeling): Observational learning is performing a behavior because others have also done that behavior with positive outcomes. Getting flu vaccines at a workplace is good because all of your coworkers and bosses whom you respect also get the vaccine, influencing you.
Reinforcements: Reinforcements refer to the outcomes of a person’s behavior that alter the likelihood of recurrence. If one gets the flu vaccine and doesn’t get the flu, then that behavior is reinforced so hopefully that individual continues to get the flu vaccine.
5.
Part III. Logic Model, Causal and Intervention Hypotheses, and Intervention Strategies
6. The target population for this intervention is non-healthcare workers in their worksite. This group, while not inherently disparate, won’t have as much knowledge of seasonal influenza and vaccinations as a healthcare worker and so will be less likely to seek out a flu vaccine by themselves. In addition, the worksite is a logical target to host a vaccine program since everyone has to go there and spend time there. Shahrabani and Benzion’s survey reported that only 24% of respondents got the flu vaccine in the 2006/2007 season. However, of those, 68% had been vaccinated at a worksite program, further indicating the importance of this program.
7.
| Intervention Method | Alignment with Theory | Intervention Strategy |
| Increase knowledge and awareness about influenza vaccination | This method follows the constructs of self-efficacy, reinforcement, and expectations. By increasing knowledge and awareness, an individual’s understanding of the potential outcomes of vaccination vs non-vaccination should make them realize the large benefits to be gained, influencing expectations and potential reinforcement. Self-efficacy would increase because people would realize that they are able to take control of their health with regards to flu. | The primary intervention strategy for this would be advertising. This advertising would focus on the benefits of receiving the vaccine and the dangers of not getting it. |
| Lower the barrier of entry to receive influenza vaccine | By lowering the barrier of entry, the primary construct which is benefited is behavioral capability. This would increase each employee’s ability to actually get the vaccine. | Offering low-cost, on-site influenza vaccination programs, so there’s not an economic barrier, and it’s convenient being in a place where employees go every day. |
| Encourage the higher-ups in the company to be the first adopters of the vaccination program | This method focuses largely on modeling, where because the bosses and those respected in the company get the vaccine, it’s more likely that the lower workers would follow their example and model their behavior after. | Focus first advertising efforts on the higher-ups of the company for them to distribute and for the effects to trickle down the hierarchy. |
9.
| Inputs/Resources | Activities | Outputs | Short-term Outcomes | Intermediate Outcomes | Long-term Outcomes |
| Funding for the hiring of a third party company and their personnel to actually conduct the flu vaccination program.Funding for production of advertising material, whether that’s that same company or some other source.The time it would take to actually conduct for each worker. Space either in-house or outdoors nearby. | Advertising the program itself and the health benefits of vaccination.Offering low-cost, on-site influenza vaccination programs. Focus first advertising efforts on the higher-ups of the company for them to distribute and for the effects to trickle down the hierarchy. | This program would occur annually. Most advertising would be done through corporate e-mail so little printing will be required, but at least one flyer should still be posted on every bulletin board around the worksite. One email should be sent every week for the month leading up to the program, where two emails will be sent on that week. A reasonable goal would be for 70% of employees to be vaccinated through this program. | Increase in self-efficacy and knowledge of health and vaccinations. Increase behavioral capability to get vaccine. Follow modeling of peers and higher-ups. Increase motivation to get the flu vaccine. | Get the flu vaccine. | Do not personally contract the flu. Limit the potential of spread through herd immunity in the workplace. Promote vaccines within social circles of friends and family, also increasing herd immunity. Miss less work and increase quality of life due to lack of flu symptoms. Promote further self-efficacy about one’s own health in general. |
10.
Intervention Hypotheses
Advertising the vaccine program to the overall company and employee body will lead to increased self-efficacy and knowledge of health and vaccinations.
The actual on-site, low-cost or free vaccine program will lead to increased behavioral capability and motivation to get the vaccine.
Advertising to the higher-ups in the company will lead to increased motivation to get the vaccine and modeling of peers and bosses leading to vaccination.
Causal Hypotheses
Increases in self-efficacy and knowledge of health and vaccinations will increase the proportions of employees who get the flu vaccine and therefore also decrease flu symptoms, increase herd immunity, and decrease work missed.
Increases in behavioral capability to get vaccine will increase the proportions of employees who get the flu vaccine and therefore also decrease flu symptoms, increase herd immunity, and decrease work missed.
Increases in modeling of peers and higher-ups will increase the proportions of employees who get the flu vaccine and therefore also decrease flu symptoms, increase herd immunity, and decrease work missed.
Increases in motivation to get the flu vaccine will increase the proportions of employees who get the flu vaccine and therefore also decrease flu symptoms, increase herd immunity, and decrease work missed.
In addition, increases in knowledge and self-efficacy about the flu will increase self-efficacy about one’s health in general, since it shows they have an increase in control about flu which will extend to other areas as well.
11.
Outcome: Increase in knowledge and awareness regarding effects of vaccines.
Objective: Following advertising about the effects of vaccination, 90% of employees will be able to pass a knowledge exam about the facts and effects of flu vaccination.
Objective: At follow-up 9 months later, 80% of employees will be able to pass the same knowledge exam.
Outcome: Increase in self-efficacy of health and vaccinations.
Objective: Following advertising, a greater proportion of employees will feel as if they have more control over their personal health compared to prior to advertising.
Outcome: Increase behavioral capability to get vaccine.
Objective: 90% of employees will report that it was easier to get the vaccine through the program than through any other means in the post-program survey.
Outcome: Follow modeling of peers and higher-ups.
Objective: At least 90% of “higher-ups” as defined individually by each company will receive the flu vaccine through the program.
Outcome: Increase motivation to get the flu vaccine. Get the flu vaccine.
Objective: A greater proportion of employees will get the flu vaccine this year compared to the year prior without the low-cost, on-site program.
Part 4. Evaluation Designs and Measures
12.
| Stakeholder | Role in Intervention | Evaluation Questions from Stakeholder | Effect on Stakeholder of Successful Program | Effect on Stakeholder of Unsuccessful Program |
| Each individual employee | Target population and program participants. | Why should I get the flu vaccine? Isn’t the flu vaccine ineffective? How much will it cost? | Get the flu vaccine.Better likelihood of not personally contracting the flu. Limit the potential of spread through herd immunity in the workplace. Promote vaccines within social circles of friends and family, also increasing herd immunity. Miss less work and increase quality of life due to lack of flu symptoms. Promote further self-efficacy about one’s own health in general. | Potentially contract the flu. Increased mistrust in the medical establishment. Loss of self-efficacy regarding the flu vaccine and their own health. Potentially miss work and spread flu to surrounding individuals. |
| Workplace executives | Responsible for approval and implementation. | How will this program benefit the company? What is the efficacy of the flu vaccine? How much will this cost to implement? | Decrease in lost work time due to flu. Increase in morale because less individuals are sick. Increase in efficient work time. Potential long term increase in overall health of employees further increasing output. Net gain in revenue. | Increase in lost work time due to flu. Decrease in morale and efficient work time because more individuals are sick. Loss of money from the implementation of the program.Potential loss of respect by colleagues. |
| The third-party flu vaccine company | Responsible for the actual program details, carrying it out, and providing advertising materials. | Will the amount of employees be sufficient to warrant putting on a whole program? How much money will we make?Is there enough space? | Increase the amount of influenza-resistant individuals. Revenue for putting the program on. Increased trust in the company leading to more clients and opportunities. | No increase in the amount of influenza-resistant individuals. Decreased trust in company leading to fewer clients and opportunities. |
13.Evaluation Design
Group randomized control trial
Intervention group A: R O1 X O2 O3
Intervention group B: R O1 X O2 O3
Control group: R O1
(O1=pre-test; O2=post-test at one day after X; O3=post-test at one year after O1)
Each group will ideally be comprised of a number of companies across multiple sizes, industries, and geographic locations. They would then be matched as well as possible between intervention groups and the control group in order to be able to better compare and stratify the data.
The control group will not be given a post-test, because there is no intervention so theoretically there will be no difference between pre- and post- any kind of treatment group.
Intervention group A: Company-wide advertising efforts which explain both the health effects of the flu vaccine and that the company is holding a free, on-site flu vaccine program.
Intervention group B: Company-wide advertising efforts which shows only that the company is holding a free, on-site flu vaccine program.
Control group: no advertising and no free, on-site flu vaccine program.
The pre-test will be administered prior to influenza season and prior to the program. The first post-test (O2) will be administered one day after the program for each intervention group. The second post-test(O3) will be administered one year after the original pre-test. The tests will assess: employees’ attitudes and opinions regarding the flu vaccine, desire to obtain the flu vaccine, current barriers to getting it, vaccination history, reasons for and against getting the vaccine, and feelings of control around the flu.
Threats to Internal Validity
Selection Bias – It will be difficult to recruit companies to participate in the program because it might be hard for executives to imagine intangible, abstract benefits like decreasing work days lost. These effects also are not immediate, so they might view it as spending money for no real benefit towards the company. As a result, we might not get enough companies or they might not be perfectly matched between study groups. In order to try to account for this, we can reach out to many different companies rather than just a select few in order to try to create as high a likelihood as possible to recruit a quorum of companies.
Attrition – It may be difficult to continue to get employees to complete follow-up surveys, and this threat to internal validity is common to all survey-focused programs. The most effective forms of maintaining follow-up would be to ensure contact information for participants is updated and to provide some incentives in the form of something like a gift card.
History – Flu vaccine advertising is relatively prevalent throughout the US and on the internet. As a result, their opinions might be influenced not by the corporate advertising but by external forces. In order to minimize this, matching groups between study groups would potentially reduce this phenomenon because hopefully employees would be exposed to the same or similar external advertisements.
14.
| Short-term or immediate outcome variable | Scale, questionnaire, assessment method | Brief description of instrument | Example item | Reliability and/or validity description |
| Increase in self-efficacy and knowledge of health and vaccinations. | The survey put together by Ofstead et al. in 2013. | A 63 item survey and content test which is able to be completed in less than 10 minutes and which was reviewed by content experts and survey design experts. | True or false: Influenza is the same as “stomach flu” | The reliability of the survey was not measured by Ofstead et al. but it will be measured in this study based on Cronbach’s alpha. Both face and content validity were supported using a review of the literature, the inclusion of questions from the Influenza Prevention Survey, and expert review. |
| Increase behavioral capability to get vaccine. | The survey put together by Shahrabani and Benzion which is based on Blue and Valley’s questionnaire. | It is a questionnaire regarding socio-demographic info, vaccination history, intent for vaccination, motivation for vaccination/non-vaccination, barriers to vaccination, perceived probability of contracting influenza without vaccination, and aspects of the Health Belief Model. | Rate your intention to be vaccinated if the flu shot is offered free of charge at theyour place of work from 1 (“certainly I will get the vaccine in thenext year”) to 5 (“I will definitely not get the vaccine in the next year”). | Content validity was maintained through a pilot questionnaire and the use of an already established questionnaire in Blue and Valley’s. |
| Follow modeling of peers and higher-ups. | The survey put together by Ofstead et al. in 2013 will be used again. | A 63 item survey and content test which is able to be completed in less than 10 minutes and which was reviewed by content experts and survey design experts. The survey includes questions about overall motivations for vaccination/non-vaccination as well as sources of advice about vaccination and preferences for receiving health information from their employer, so it is appropriate to use in this context. | “From what sources do you prefer to receive information about vaccinations?” | The reliability of the survey was not measured by Ofstead et al. but it will be measured in this study based on Cronbach’s alpha. Both face and content validity were supported using a review of the literature, the inclusion of questions from the Influenza Prevention Survey, and expert review. |
| Increase motivation to get the flu vaccine. | The survey put together by Ofstead et al. in 2013 will be used again. | A 63 item survey and content test which is able to be completed in less than 10 minutes and which was reviewed by content experts and survey design experts. The survey includes questions about overall motivations for vaccination/non-vaccination, so it is appropriate to use in this context. | “Mark yes or no for each reason for accepting the flu vaccine: Free or low cost; Avoid missing work; Convenient; Not to transmit flu; Doctor advice, etc” | The reliability of the survey was not measured by Ofstead et al. but it will be measured in this study based on Cronbach’s alpha. Both face and content validity were supported using a review of the literature, the inclusion of questions from the Influenza Prevention Survey, and expert review. |
Part 5. Process Evaluation and Data Collection
15.
Recruitment and enrollment
Corporate Recruitment: this letter will go out to all identified potential companies
Dear Company,
The University of Georgia School of Public Health in partnership with Flu Vaccine Program Company would like to invite you and your company to be a part of a reduced-cost, on-site influenza program and study which will reduce the rate of influenza and missed work days due to influenza in your employees. The program will take place on your worksite and will offer flu vaccines to all of your employees. In addition, advertising materials will be provided to you to disseminate throughout the company. Surveys will be given out to your employees regarding things like knowledge about the flu and its vaccine and current attitudes towards the vaccine among others.
All information collected will be strictly confidential and used for study purposes only. If you would like to participate or would like any more information, please contact us at xxx-xxx-xxxx or at xxx@uga.edu.
Sincerely,
Influenza Vaccine Program Coordinator
University of Georgia School of Public Health
| Company Name | Number of Employees | Industry | Location | Contact Name | Contact Email | Contact Phone Number |
Attrition
Each employee who gets the flu vaccine through the program will fill out this contact information form to get the most up-to-date information. Those who do not, however, won’t get the form to fill out. For the pre-test, the employer will provide contact information for all employees.
On-site, Reduced Cost Influenza Vaccination Program Contact Form
Name:
Company:
Email:
Phone Number:
Address:
All information collected will be strictly confidential and used for study purposes only. If you would like any more information, please contact us at xxx-xxx-xxxx or at xxx@uga.edu.
Fidelity
In order to assess the fidelity of the program, this survey will be sent to the company’s contact following the program and O2.
Please remember that all information will remain anonymous and is strictly confidential. None of this information will be used in an identifiable manner to your company.
Company name:
What percentage of the employees received a flu vaccine through this program?
Approximately what percentage of your employees were exposed to advertising through e-mail?
How often were e-mails advertising the program sent?
Approximately what percentage of your employees were exposed to advertising through bulletin board postings?
On what percentage of bulletin boards were advertisements or flyers posted?
How long were these advertisements on bulletin boards before changing them?
Do you anticipate that your company would like to participate again for the next flu season?
What difficulties did you encounter during implementation of this program? How would you fix them?
REFERENCES
Nowalk, M. P., Lin, C. J., Toback, S. L., Rousculp, M. D., Eby, C., Raymund, M., & Zimmerman, R. K. (2010). Improving Influenza Vaccination Rates in the Workplace. American Journal of Preventive Medicine, 38(3), 237–246. doi:10.1016/j.amepre.2009.11.011
Ofstead, C. L., Sherman, B. W., Wetzler, H. P., Langlay, A. M., Mueller, N. J., Ward, J. M., . . . Poland, G. A. (2013). Effectiveness of Worksite Interventions to Increase Influenza Vaccination Rates Among Employees and Families. Journal of Occupational and Environmental Medicine, 55(2), 156-163. doi:10.1097/jom.0b013e3182717d13
Shahrabani, S., & Benzion, U. (2010). Workplace Vaccination and Other Factors Impacting Influenza Vaccination Decision among Employees in Israel. International Journal of Environmental Research and Public Health,7(3), 853-869. doi:10.3390/ijerph7030853