Introduction

Immunization coverage estimates are useful tools for a variety of purposes such as to monitoring the performance of immunization services in order to identify areas for improvement, as to planning strategies to eradicate certain communicable diseases and to designing an evidence-based health policy.₁ Vaccine-preventable diseases are still major causes of mortality and morbidity for people of all ages. Early vaccination against influenza viruses is the cornerstone in preventing influenza, a disease that can reach epidemic levels in any time. Influenza and pneumococcal disease are two important causes of mortality and morbidity in vulnerable population groups such as the elderly, especially in countries with temperate climates.₂,₃,₄ Simultaneous distribution of influenza and pneumococcal vaccine to the elderly is highly recommended as it is a safe and effective procedure.₅,₆ In Greece influenza and pneumococcal vaccination are recommended for people aged>65 years old and for high risk groups.

During the 2005-2006 the risk for an avian influenza outbreak received substantial global media attention, including reports of vaccine shortages leading to an excessive vaccine demand. In order to respond to these, a number of various influenza surveillance systems has been developed in Greece aiming at: (1) the monitoring of influenza activity trends in the entire country, as well as in each geographical district, (2) the detection of seasonal influenza outbreaks, (3) the identification of prevalent serotypes in order to produce vaccines, and (4) the timely identification of a possible new subtype with pandemic potential, as well as the distribution of new influenza strains (www.keel.org.gr). In Greece, influenza is a disease subject to mandatory report only when recording a laboratory confirmed case or reporting a connection to a laboratory-confirmed case.

In Greece there are no formal data about the vaccine coverage of elderly against influenza and pneumococcal disease. According to the Macroepidemiology of Influenza Vaccination Study Group₇ on the distribution of influenza vaccine (expressed as the number of doses distributed/1000 total population each year), in Greece there was an increase in the distribution of vaccine from 62/1000 total population in 1997 to 165/1000 total population in 2003. Fedson stressed that pneumococcal vaccine coverage among elderly is relatively low in the developed countries with the exception of the United States where vaccination is widespread.₈ According to the relevant literature the estimate of influenza vaccine uptake rates for the elderly in Europe₉ range from 25% to 81% as opposed to America₁₀,₁₁ ranging from 34.9% to 80.3% for the elderly who suffer from diabetes or asthma and 71.5% for the HMO members, to Canada₁₂,₁₃ ranging from 55.6% to 44.8% and to Iran₁₄ that was 68.1%. Among the twenty countries of OECD₁₅ that provided data, the annual percentage of immunized elderly people ranged from 16.5% (Czech Republic) to 79% (Netherlands). In general, many countries exceeded 60%. The rate of influenza vaccination also stood at over 60% in most G7 countries, with the exception of Germany and Japan where less than 50% of the elderly population reported having been vaccinated against influenza in 2003.₁₅

Several researchers suggested a number of reasons for low immunization rates or for refusal of influenza vaccination in the elderly population.₁₆,₁₇,₁₈,₁₉,₂₀,₂₁,₂₂,₂₃,₂₄,₂₅,₂₆,₂₇. Some other researchers have used theoretical models such as the Health Belief Model and the Multidimensional Locus of Control Theory to explain the low proportion of elderly vaccination.₁₄,₂₈,₂₉ The Health Belief Model was originally developed as a systematic method to explain and predict preventive health behaviour.₃₀ A person's motivation to undertake certain health behaviour relates to individual perceptions, modifying behaviours and likelihood of action. Individual perceptions include factors that affect the perception of illness or disease; they deal with the importance of health to the individual, perceived susceptibility and perceived severity. Modifying factors include demographic variables, perceived threat and cues to action. The combination of these factors often manifests into action. The result of this action can be interpreted as certain behaviour. According to the evidence, three of the Health Belief Model dimensions (perceived barriers, perceived benefits and perceived severity) were found to be significant predictors of the acceptance of influenza vaccination among the elderly.₂₉

The aim of the study was to explore the knowledge, the attitudes, and the beliefs of community-dwelling Greek elders towards influenza and pneumococcal vaccination in order to elicit those factors that contribute to the acceptance or to the refusal of vaccination.

Sample and method

Potential subjects who met the following inclusion criteria were selected to participate to the study: (1) willingness to participate, (2) ability to speak and read Greek (3) age 65 or above (4) no apparent cognitive impairment that was assessed from the researcher. Participants were either age-appropriate or had clinical indications to receive a strong recommendation for influenza and pneumococcal immunizations. Participants received a brief explanation of the purpose and the aim of the study and from those who agreed to participate was asked to give an informed consent. The sample of participants was randomized in time and region. Finally 22 elderly individuals were approached. In qualitative research, sample sizes are not determined by hard and fast rules but by other factors, such as the depth and duration required for each interview and how much it is feasible for the interviewer to undertake.₃₁ The mean age of the elderly participants was 70.5±5.22 years old ranging from 65 to 82 years old. Baseline characteristics of the respondents are shown in Table 1.

Figure 1

Table 1 : Demographic characteristics of the sample

In order to explore Greek elderly knowledge on influenza and pneumococcal vaccination we conducted three focus groups (8+7+7=22). Qualitative research is designed to obtain in-depth responses about what people really know, think, and feel for a certain issue. Its value relates to its ability to collect and match unfiltered comments from the representatives of a target population. We recruited our convenience sample from the community and from a senior centre. To assure geographic representiveness of the sample two focus groups were performed in two rural regions of Central (n=7) and West Greece (n=8) and the third in Athens (n=7) the capital of Greece. The focus group interviews were completed between July and September 2006.

Before starting the focus group elderly participants were kindly asked to fill out a short self-completion questionnaire that contained questions about demographic data, health history data and details about vaccination history. We asked from the participants to rate their self reported health status from 0 (very bad) to 10 (excellent). In addition, to assess disease burden and comorbidities elderly participants were asked a number of dichotomous questions on the presence of a variety of chronic diseases. Furthermore they indicated whether or not this disease caused impairment.

Focus groups questions were divided in four major categories: (1) those related to flu experience, (2) those related to flu prevention (3) those related to flu vaccination and (4) those related to flu vaccination prevention. The theoretical framework of the Health Belief Model was used to guide the comparison of differences between elderly who were immunized and those not immunized against influenza and pneumococcal disease. We tried to identify perceived barriers and facilitators related to influenza and pneumococcal immunization as determinants of a certain health-seeking behaviour. We included items that explained: (1) perceived susceptibility (e.x. how susceptible are you to flu? Why do you think some people are more susceptible to flu than others? What kind of people is more susceptible to flu? Among them, who are the most susceptible? Would you consider the impact of flu on them to be more serious?) (2) perceived seriousness (e.x. how serious do you consider influenza and/or pneumonia? What are the difficulties that would create to you?), (3) perceived benefits of Taking Action (e.x. why and who do you think would benefit from flu vaccination and hence should be highly recommended to have the flu shot?), (4) perceived barriers to taking action (e.x. why did you refuse to get a flu shot?), (5) cues to action (e.x. by whom or by what source of information were you prompted to get a flu shot? Describe how the information appealed to you) and (6) cultural practice and ethnic beliefs (e.x. describe what does flu vaccination mean to you).

To explore the "lived experiences" of elderly participants, they were asked to describe their vaccination behaviour as fully and deeply as possible until they had nothing more to say. The audiotapes were transcribed verbatim to best represent the dynamic nature of the living conversation. Each transcript was analyzed independently by two readers by the examination of key phrases and concepts about vaccination.

Data analysis

Overall, the majority of the participants were females (n=15, 68.2%), living with their family (n=19, 86.4%) and being married (n=18, 81.8%) as seen in Table 1. The mean score of self reported health status was 8.14±2.18 and the median was 9.

Seven (31.8%) participants reported a heart disease (mainly hypertension), while 5 (22.7%) reported psychological problems such as depression and anxiety, 2 (9.1%) a chronic respiratory disease, 5 (22.7%) a vascular disease, 6 (27.3%) muscoskeletal disease (mainly arthritis and osteoporosis), 5 (22.7%) a gastrointestinal disease (mainly constipation and gastric ulcer) and 1 (4.5%) a renal disease.

Participants were asked to rate their overall current health status by using a three point Likert scale ranging from not well, moderate to good. The majority of the elderly rated their current health as good (n=13, 59.1%) while the rest 40.9% (n=9) rated it as moderate. 9 (40.9%) participants thought that their health was better or similar to that of other people in the same age group whereas 4 (18.2%) found it worse. Seventeen participants declared that their current health status was similar to that of last year, while 4 (18.2%) replied it was worse and only one (4.5%) answered that it was better. The vast majority of the elderly takes medicines in a daily basis because of a chronic disease. Half of the respondents reported visiting their physician more than four times a year, while 36.4% is seeing them for two or three times a year.

All the participants were knowledgeable about flu and the flu shot and its necessity to the elderly people. On the contrary, only 6 (27.3%) have heard about the pneumococcal vaccine at least once in their life. Fourteen (63.6%) have received influenza vaccination the last year during the autumn. No one has received pneumococcal vaccine during his life. Five (22.7%) persons refused to be vaccinated against influenza. The main places that participants reported to have received the vaccine at least once in their lifetime were the physician's office, local health centres, pharmacy and in their home. Of the vaccinated respondents some were vaccinated from the nurse/health visitor in a health centre, or at a pharmacy or at home from their relative (mainly their daughter). The vaccinated elderly people reported that the flu shot is not painful as opposed to the unvaccinated who reported that they dislike shots or they are afraid of needles. Four (18%) participants reported difficulties getting the vaccine due to vaccine shortage.

Two-thirds of the elderly reported that they have experience an influenza like syndrome at least once in their life. Five of them have been infected from influenza this year while 7 reported an infection during the previous year. Four (25%) persons answered that they have never been infected in their life. The infected participants reported medium severity symptoms. Most of them recovered fully within a week. The reported symptoms were high fever, cough and loss of appetite, sore throat, runny nose, headache, myalgia and general fatigue. The main symptom was body ache. Half of them did not get drug therapy while the other half used antipyretics and bronchodilators. Only two persons reported more than two episodes of influenza yearly.

To explore how elderly people differentiate influenza from respiratory track infections we asked them directly what is the difference between these two health conditions. Table 2 shows some of their answers. Additionally we forwarded the following question: “can you tell us the difference between pandemic influenza and avian flu?” Table 2 shows also some of their answers.

Figure 2

Table 2

Eight respondents who had never gotten the flu vaccine in their lifetime were encouraged to give a free response reason. The most common reason for not ever receiving a flu shot was the belief that the person is currently healthy or does not belong to a high risk group for getting the flu. Furthermore they harboured doubts about the vaccine safety: “...I am afraid about the side effects of vaccination. A week after the vaccination I suffer from influenza like symptoms and mainly sneeze...” This was a common comment that was associated with an unleasant previous experience.

Some respondents found it difficult to explain why they have never got the flu vaccine. Their answers were: “... I don't know. I have never thought why...” or “...simply I don't want the flu shot...” In Table 3 are summarized some of the answers and are grouped according to the Health Belief Model. Five very old participants mentioned that a relative (mainly their daughter) brought them the flu vaccine.

Figure 3

Table 3

Two thirds of the vaccinated elderly participants declared that although not susceptible to influenza they got the flu as a preventive measure. They believed that they are able to reduce or even eliminate the likelihood of getting the flu by avoiding the direct contact with infected persons, by eating well and by keeping a stable temperature in the environment they live. Those non-vaccinated promoted the fact that flu shots are for the “very old people” or for people who are sick or weak.

Half of the participants replied that people living in their community are quite vulnerable to influenza virus infection as they are not well informed. When we asked them why they think some people are more susceptible to flu than others, the majority replied: “due to bad immune system”, “due to poor health” and “because they do not take preventive measures”. In addition elderly participants argued that the most susceptible to flu are the very old people, those who suffer from chronic cardiovascular diseases, children and newborns. They all believed that these people belong to a high risk population and considered the impact of flu on them to be more serious. All indicated flu vaccine as the most effective preventive measure for flu in combination with nutritious food, avoiding the society of other infected individuals, sanitation, avoiding visiting indoors places, personal hygiene and cleanliness. When we asked from the participants to rank these preventive measures according to their perceived importance, all recommended that the vaccine is the first choice for those who want to be protected against influenza.

Knowledge and beliefs about flu, pneumonia and related vaccines

Source of information

Discussion

Influenza and pneumococcal infections are two serious public health problems that cause significant mortality and morbidity particularly in the elderly and other high-risk groups. This study demonstrates the main motives and barriers that explain why elderly people chose or avoid respectively to get vaccinated against influenza and pneumonococcal disease. Almost two-thirds of the elderly participants have received flu vaccine last year. Some researchers report low vaccination rates and others report satisfactory proportions.₉,₁₀,₁₁,₁₂,₁₃,₁₄,₁₅,₁₉,₂₀,₂₁,₂₂,₂₃ In fact monitoring of influenza vaccination uptake in Greece as well as in Europe is underdeveloped.₉ Only half of the European countries monitor and document the proportion of elderly vaccinated people. In Greece no official data are available.₁₅

Many factors have a synergic relationship with the final behaviour of elderly participants. A key influence on specific elderly behaviour is physicians' recommendations, as some elderly mentioned that they did not get the flu because of a lack of a clear position on vaccination by their physician. Our findings are congruent with other studies.₁₄,₁₈,₁₉,₂₀,₂₁,₂₃,₃₂This was also supported by other researchers regarding pneumococcal vaccination.₁₇,₂₂ Greek physicians and especially internal medical doctors play a central role in motivating elderly people to get a flu shot. An in depth investigation of this finding showed that elderly either forget to ask directly their physician, or have a negative attitude towards immunization and are negatively predisposed, or they do not recall what their physician advised them, or their physician really lack updated knowledge on the benefits of vaccination. In some cases physicians really fail to persuade their patients to get the flu shot, or even to provide adequate information and advice about the effectiveness and the side effects of influenza vaccine.₁₄,₂₄,₂₆,₃₃On the other hand those elderly who visit their physician very often for screening purposes or for drug prescription were more likely to ask for an advice regarding flu shot and to get the flu vaccine. It has to be mentioned that in 85% of the European countries the GP is the main distribution channel for vaccine provision to the population at risk.₉ In some other countries public health Organizations and institutional physicians administer the vaccine. In Greece the system of vaccine provision is mixed as healthy elderly people can either buy the vaccine by themselves own without drug prescription from the physician, or they take it after a prescription from an internist, or a GP, in the hospital, in the health centre or in the KAPI. The persons who carry out flu shot is in most of the cases the nurse, the heath visitor, the pharmacist, the unlicensed nurse or even a relative.

For many other researchers the strongest predictive factor of future flu shots is whether they received a flu shot this year or in the past.₂₁,₂₈In our analysis this was also a main factor that contributed to the refusal of the vaccine this year or in the future as persons who experienced side effects or unpleasant reactions were also more likely to avoid future flu shots. This attitude combined with misperceptions and misunderstandings of the elderly about how the vaccine “works” explained why some elderly participants do not continue getting the vaccine. It is remarkable that the overwhelming majority of our participants think that flu vaccine causes influenza with minor symptoms.₁₄The comments of the individuals in Table 2 reflect their beliefs regarding the mechanism of the flu shot.

Judging from the results obtained for the very old participants who live with their children or their partner, the most important factor for being vaccinated is “having a relative who delivered the vaccine at the beginning of autumn”. The catalytic role of the family in the acceptance of influenza vaccine among the elderly people was previously supported₁₄,₃₂and in case of Japan was attributed to cultural differences. The role of family was previously documented in Greek.₃₄ In fact the Greek elderly people adapt their behaviour according to the “values” of their family.₃₅,₃₆ Values are clear statements about what is right, wrong, good, bad; thus, they are within the realm of moral claims. Human values are often referred to as relatively stable beliefs about the personal or social desirability of certain behaviours and modes of existence known as “subjective norms” that depend on values for their ultimate support.₃₆In fact elderly persons feel social and moral pressure to get the flu shot. This explains why elderly individuals justify either following or not following a norm that in our case is the acceptance of a flu vaccine. A usual comment of the participants was “I was vaccinated to protect my family from getting the flu” and shows that decision making is an interpersonal process between family members. The paternalist model of informal care provided from the daughters to their elderly parents determines their health behaviour. Greek elderly follow a tacit rule that could be articulated as something like: "don't try to change your World; just receive whatever is provided to you". Elderly people grasp most rule of social behaviour in the same way that they grasp "rules" of grammar.₃₆

All the participants counted a number of possible alternative ways that could prevent influenza, such as to stay at home, to avoid getting wet or chilled and to eat enough.₂₇,₂₉In our study all the individuals assumed that flu vaccine is the most effective preventive measure. In another research₂₇ the percentage was 65%.

Overall, about one third of the participants have received influenza vaccination. Although they were in a risk group, as they suffered from chronic pulmonary or heart disease and diabetes, and so were eligible for pneumococcal vaccination no one has ever received a pneumococcal shot. Only 27.3% of the participants have heard about the pneumococcal vaccine at least once in their life but no one has received pneumococcal vaccine during his life. Not many of the individuals knew enough about the pneumococcal vaccine, a finding that is in accordance with the research of Santibanez.₂7

A leading reason for non vaccination reported from the elderly participants was vaccine unavailability.₁₇,₂₅,₂₇,₃₇Recent problems with vaccine shortages have delayed or even limited the access to vaccination. In Greece during 2005-2006 influenza season the global media attention to the risk of an avian influenza pandemic has emerged the need of elderly and other high risk groups to get vaccinated. As a result there was an increased demand for vaccines. Some elderly participants commented their difficulties in finding the flu vaccine.

Prevalence rate for the refusal of influenza vaccination was relatively low (22.7%) in comparison with other studies₁₆,₃₈,₃₉ that mentioned a prevalence ranging from 12% to 16%. Non-immunized individuals perceived more barriers to getting vaccinated. Some elderly participants criticized the whole process of prescribing and getting the flu vaccine as they had to make an appointment with their physician, to prescribe the vaccine and then to buy it from the pharmacy and revisit the health centre or the physician to carry out the flu shot, a rather time consuming procedure. They found it very complicated and they perceived it as a barrier for vaccination. In Greece influenza vaccination is covered from the Health Insurance. We note that the cost per vaccine is about 5€. Elderly participants aged less than 75 years old disliked the previous mentioned bureaucratic process and finally bought the vaccine themselves as they believed that the cost was too low. This finding suggests that a more client friendly procedure would be appreciated from this category of elderly people and would encourage them to receive the vaccine.

Some non vaccinated elderly participants from rural regions reported difficulty in reaching the medical centre or the physician as the main cause of their vaccination behaviour.₄₀The geographic disparities faced by the elderly who live in the rural regions represent a major barrier to the appropriate delivery of the vaccine. The expanding use of home care visits in these regions would contribute to the increase in influenza and pneumococcal vaccination uptake.

Common reasons unvaccinated respondents cited for not receiving vaccination included the belief that it was unnecessary, the belief that vaccination would cause illness, and failure to think about it.₂₅,₃₂The majority of older people do not consider themselves eligible for vaccine uptake as they do not perceive themselves to be at risk of serious consequences of influenza.₃₉In the United States approximately 40% of Medicare beneficiaries who reported not receiving recent influenza and pneumococcal vaccinations cited concerns about the vaccine, including thinking it could cause influenza, could have side effects, or would not prevent influenza.₁₇,₂₃

Many researchers have used several methods to improve the uptake of influenza vaccination among the elderly people. These methods varied from personal mailed letters,₄₁,₄₂,₄₃,₄₄ postcard influenza vaccine reminders (Armstrong, 1999) through mailed educational brochures,₄₅ to computerized reminders₄₆ and nurse-initiated protocols.₄₇ In Greece no automated or even a manual system for reminding eligibly elderly people to get the influenza or pneumococcal vaccine is available. Public health care makers should evaluate the potential of a reminder system as it is an effective measure to improve the vaccination uptake and to monitor the progress of the system. It is a measure that adds “value” to the consumer of health care services and assures his active participation to his health promotion.

There are limits to the study to be discussed here. We did not select a random sample. However, we decided to proceed with a convenient sample. A further concern was that due to language barriers, our sample consisted chiefly of persons fluent in spoken and written Greek. Despite these restrictions, we decided to proceed, as we believed that this study could serve as a precursor for future research.

Conclusions

The study provides an insight and in-depth understanding of the factors that contribute to the elderly immunization decision making and demonstrates the appropriateness of the Health Belief Model as a theoretical framework that delimits all the prerequisites of a certain health seeking behaviour, which is influenza vaccine uptake. The results of the study provide implications for further research. Availability of sufficient vaccines to meet the needs of elderly is crucial in the beginning of autumn. Previous experience affords the opportunity to examine alternatives for future evidence based interventions. Focused health education programs incorporated in a national campaign to sensitize and educate seniors and their health care providers towards influenza and pneumonia are needed to increase the uptake of influenza and pneumococcal vaccination. The program should clarify the absence of systemic side-effects, the efficacy of the vaccine and the danger of the complications associated with influenza.

Acknowledgments

Correspondence to

Dr. Raftopoulos Vasilios Address: 3 Makelaraki Street, Perissos, Nea Ionia, 142-32 Athens. GREECE Telephone number: 0030 210 2522001, Fax number: 0030 210 8899264 Email: v_raftop@yahoo.gr and raftopoulos@keelpno.gr