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January 4, 2010

Health Care Worker Knowledge, Attitudes, and Beliefs Regarding Mandatory Influenza Vaccination

Author Affiliations

Copyright 2010 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2010

Arch Pediatr Adolesc Med. 2010;164(1):33-37. doi:10.1001/archpediatrics.2009.252

Objective  To determine the attitudes, beliefs, and knowledge of children's hospital health care workers toward mandatory influenza vaccination.

Design  Self-administered, Web-based questionnaire.

Setting  A large, tertiary children's hospital.

Participants  A random sample of 585 health care workers, including physicians, nurses, and all other hospital employees.

Outcome Measure  Attitudes of health care workers toward mandatory policies for annual influenza vaccination of health care workers as related to their opinions on safety, effectiveness, and knowledge about influenza and influenza vaccination.

Results  Many employees (70%) thought influenza vaccination should be mandatory for health care workers who did not have a medical contraindication. Nearly everyone, 363 of 391 (94%), who favored mandatory immunization had been immunized themselves. Of those who opposed mandatory immunization, 45 of 81 (55.6%) had been immunized (P < .001). Individuals who supported mandatory policies were more likely to believe that the vaccine is safe for both children and adults. There was no significant difference between the percentages of promandate and antimandate employees who believed influenza was dangerous for the patients where they work (66.5% and 62%, respectively, P = .07). Only 29% of antimandate employees believed they were at high risk of contracting influenza, compared with 51% of promandate employees (P < .001).

Conclusions  Approval of mandatory influenza vaccine policies was high; however, attitudes about the dangers of influenza for patients were not associated with acceptance of mandatory vaccination policies for health care workers. Educational efforts targeting health care workers' fears and misconceptions about influenza vaccines might help to decrease the reservoir of unimmunized health care workers.

Influenza is responsible for an estimated 36 000 deaths and 226 000 hospitalizations every year in the United States.1 Children and the elderly are at particularly high risk of influenza infection.1-3 The Centers for Disease Control and Prevention recommend that all health care workers (HCWs) receive an annual influenza immunization to protect themselves and their patients. Nevertheless, only 40% of HCWs in the United States get immunized every year.2 While immunization rates at hospitals caring for children have generally exceeded the national rate, a 2004 study of 19 children's hospitals revealed very low rates of immunization in some hospitals and among HCWs in some high-risk units.4

Health care workers give many reasons for not getting immunized.3,5-8 Many underestimate the dangers of influenza for themselves and their patients.5-8 They do not know that they are contagious before they are symptomatic and therefore may represent an underrecognized cause of nosocomial spread.9-12 They also overestimate the risks of influenza vaccines.3,5,6 Some claim to be too busy and some do not want to pay for the vaccine. To address these objections, hospitals have offered comprehensive education programs, along with free and convenient immunizations. These programs increase immunization rates.13-15 Some programs, including ours, require HCWs who turn down the influenza vaccine to sign a declination form stating that the vaccine was offered and that they refused it.15,16 In programs in which declinations were implemented, modest improvement in vaccination rates among employees have been noted. However, in some cases, employees simply refused to sign the declination. Overall, the impact of declinations is difficult to evaluate, as the language and context typically vary hospital to hospital, and often multiple other strategies are implemented concurrently. Some have argued that mandatory policies should be instituted to achieve universal coverage of HCWs.17,18

Health care workers in children's hospitals may have a unique perspective on influenza vaccines because they routinely recommend other vaccines for children and see the effects of underimmunization. In this study, we examined the attitudes of children's hospital HCWs toward a hospital policy of mandatory influenza vaccination and what differences might exist between employees who favored a mandate and those who opposed one.


In April 2009, a 44-item survey, adapted from 2 separate surveys used by Looijmans-van den Akker et al19 and Gust et al,20 was sent to a random sample of physicians, nurses, and all other employees at a large, tertiary children's hospital. To select patients from each group of employees, we obtained lists of all physicians, nurses, and other employees. We then used the random sampling feature of Excel software to select them for our study sample. We oversampled physicians to get enough physician responses to allow for meaningful comparisons between employee groups. The sample included 40% of all physicians (n = 117), 18% of all nurses (n = 236), and 18% of all other employees (n = 593) at the hospital. The latter group included nonclinical staff, such as researchers and housekeeping, dietary, child life, security, and cafeteria workers, as well as care assistants and phlebotomists. We did not analyze each group of other employees. The selected individuals were sent an e-mail that explained the nature of the survey and included a link to the Web-based survey available on a secure, online account. Included in the e-mail was an opt-out link for employees who chose not to participate. We sent weekly e-mail reminders to nonrespondents for 6 weeks. The study period ended in mid-May 2009.

We calculated childhood vaccination rates by categorizing children as up to date or not based on parent responses. We did not independently verify childhood immunizations. Children younger than 6 months were excluded from analyses for influenza vaccine uptake, as they are too young to receive the vaccine. We classified any HCW who “strongly agreed” or “agreed” with a mandatory HCW vaccine program as promandate and those who “strongly disagreed” or “disagreed” as antimandate.

First, we determined HCWs' opinions toward a mandatory influenza vaccination policy at their institution. Then, we assessed how HCWs' approval or disapproval toward mandatory policies was associated with their knowledge, attitudes, and beliefs about influenza infection, influenza vaccine, and childhood vaccines. We also determined whether there were any associations between HCWs' opinions of a mandatory influenza vaccination policy and the rates at which HCWs vaccinated themselves and their children against influenza.

Using SPSS, version 17 (SPSS Inc, Chicago, Illinois), we compared categorical variables using the χ2 or Fisher exact tests. We compared Likert scale responses using the Kruskal-Wallis and Mann-Whitney U nonparametric tests. The study was approved by our institutional review board.


A total of 946 surveys were successfully distributed to employees of the children's hospital. We received 574 responses, for an overall response rate of 61%, which included 63 of 117 physicians (54%), 135 of 236 nurses (57%), and 376 of 593 other employees (63%.) Twenty-six employees (3%) refused to participate in the survey. Eighty-two percent of respondents were female, 83% were white, 53% were aged 25 to 44 years, and 40% had more than 15 years of experience as an HCW.

Overall, 85% of respondents received an influenza vaccine for the 2008-2009 season. Physicians and nurses were more likely than all other employees to be immunized (96%, 93%, and 77%, respectively, P < .001).

Ninety-eight percent of respondents were aware that the institution offered free vaccines. Almost half (48.5%) falsely believed that the hospital required them to get vaccinated against influenza.

Most employees (70%) either strongly agreed or agreed that the hospital should mandate influenza immunization (Figure 1). Employees who had received the influenza vaccine were much more likely to favor a policy of mandatory influenza vaccination than those who had not. Other determinants of a positive attitude toward mandates are presented in Table 1. Nearly 15% of respondents opposed a mandatory immunization policy. About half of these respondents (56%) had been vaccinated against influenza.

Figure 1.
Health care workers' level of agreement with the statement “Health care workers should be required to receive an influenza vaccine unless they have a medical reason not to.”

Health care workers' level of agreement with the statement “Health care workers should be required to receive an influenza vaccine unless they have a medical reason not to.”

Table 1. 
Characteristics of Survey Respondents for and Against Mandated Influenza Vaccination
Characteristics of Survey Respondents for and Against Mandated Influenza Vaccination

Comparing those who favored a mandate with those who opposed one, knowledge about Centers for Disease Control and Prevention recommendations was high for both groups and there were no significant differences in knowledge about the dangers of influenza for patients (Table 2). Employees who favored the mandate were more likely to believe that immunization was safe for both children and adults. Employees who opposed the mandate were more likely to report that they oppose mandates for routine childhood immunizations and favor parental authority concerning whether children receive immunizations (Table 3). Only 29% of antimandate employees believed they were at high risk of contracting influenza compared with 51% of promandate employees (P < .001).

Table 2. 
Differences in Knowledge About Influenza and Influenza Vaccine Between Promandate and Antimandate Employees
Differences in Knowledge About Influenza and Influenza Vaccine Between Promandate and Antimandate Employees
Table 3. 
Beliefs About Influenza Vaccine and Childhood Vaccines Between Promandate and Antimandate Employees
Beliefs About Influenza Vaccine and Childhood Vaccines Between Promandate and Antimandate Employees

Employees who oppose an influenza mandate were equally likely as those who favor one to report that their children are up to date on all recommended childhood vaccines (119 of 125 [95%] vs 27 of 29 [93%]). However, employees who favored a mandate were more likely to report that their child received the influenza vaccine than those who opposed a mandate (72 of 97 [72%] vs 7 of 22 [32%], P < .001). Seven employees were excluded from analyses because their children were too young to receive an influenza vaccine.

Nearly half of HCWs who disagreed with the mandate received the influenza vaccine in the last year. Comparing only antimandate HCWs who had themselves been immunized with those who had not, immunized HCWs were much more likely to believe that the influenza vaccine is safe for adults and children and that they have a high risk of contracting influenza (Table 4).

Table 4. 
Belief and Knowledge Differences About Influenza and Influenza Vaccine Among Antimandate Employees by Vaccination Status
Belief and Knowledge Differences About Influenza and Influenza Vaccine Among Antimandate Employees by Vaccination Status

Overall, only 2% (12 of 585) of employees said they would quit if the hospital mandated an influenza vaccine. They were all in the antimandate group and comprised 15% of that group (Figure 2).

Figure 2.
Percentage of respondents who would quit their jobs if their employer required them to get an annual influenza vaccine.

Percentage of respondents who would quit their jobs if their employer required them to get an annual influenza vaccine.


In this study of employees at a children's hospital, knowledge about influenza infection and influenza vaccination was high, as was the rate of influenza vaccine coverage, though this was significantly different between promandate and antimandate groups. Despite the high immunization rate overall and relatively high knowledge scores, 15% of HCWs at this hospital opposed a policy that would require the influenza vaccine for all HCWs. A small number said that they would quit if they were required to receive the influenza vaccine.

The study has several limitations. Despite our 62% response rate, we have no information about nonresponders. The nature of the survey may have led to a social desirability bias—people who had been immunized or who favored mandatory immunization might have been more likely to respond than those who did not. Still, the rates of immunization reported by our respondents were similar to those reported by the hospital infection-control officer.

Second, our questions about people's responses to a mandatory policy were theoretical. There is no way to know how people would respond if such a policy were actually implemented.

Third, we cannot validate parental responses about whether their children had received all recommended childhood vaccines. It is possible that these responses overestimated or underestimated actual vaccination rates.

Even with those limitations, however, our data suggest that employees who oppose mandated vaccination seem to fall into 2 groups. One group simply misunderstands the facts about influenza or the vaccine. Better education programs would reduce the size of this group. A second group, however, understands the facts but disagrees about values. They think that decisions about immunizations—whether for HCWs or children—should be up to the individual. They may oppose mandates for deep philosophical reasons. These workers present a complex challenge for hospitals and society. Should they be forced to choose between their personal beliefs and continued employment?

Hospitals mandate many things to prevent nosocomial infections: equipment is sterilized; frequent handwashing is enforced; isolation procedures are used for patients with contagious illnesses; and evidence of noninfection or immunity is routinely collected with tuberculin skin testing and serologic response to vaccines for employees. All of these interventions are expensive for hospitals and may be burdensome for HCWs. Nevertheless, a HCW who refuses to comply with such hospital polices would not be well tolerated. It should be no different for influenza immunization.

There are many good reasons why all HCWs should be immunized against influenza. They are at high risk of contracting the disease themselves, which can lead to spread of the disease to their vulnerable patients, compromising patient safety.9-12 Health care workers are role models who can influence whether their patients and peers get vaccinated.21,22 Unimmunized HCWs who become ill will miss work and this may lead to lower quality of care.23,24 For all of these reasons, one could see immunization as a duty of professionalism and, as the American Nursing Association suggests, “an ethical responsibility,” even if it carries a small amount of risk. The American College of Physicians' Charter on Professionalism states that a duty to professionalism, “demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health.”25

Given the known efficacy of the vaccine,23,24,26,27 the strong recommendation of all professional organizations for universal vaccination of HCWs,1,2 the known shortfalls in voluntary programs,5-8 the likely improvements to patient safety, and widely agreed upon duties of professionalism, institutional mandates for flu vaccine are ethically defensible. The next question that will need to be answered is, assuming that mandates are ethically defensible, whether they will effectively increase immunization rates. Some states have recently passed laws mandating influenza immunizations and preliminary data suggest that participation by HCWs has increased.28 A recent study shows that a mandatory influenza vaccination policy increased vaccination rates in a large, multihospital health care system, with fewer people seeking exemptions than had previously signed declination statements. The program was successful. More than 98% of the 25 000 HCWs in this multihospital system were immunized.29 The next frontier will be demonstrating the success of the programs in terms of patient safety and quality of care.

Correspondence: John D. Lantos, Children's Mercy Bioethics Center, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108 (jlantos@cmh.edu).

Accepted for Publication: October 15, 2009.

Author Contributions: Dr Myers had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Douville, Myers, Jackson, and Lantos. Acquisition of data: Douville, Myers, and Lantos. Analysis and interpretation of data: Douville, Myers, and Lantos. Drafting of the manuscript: Douville, Myers, Jackson, and Lantos. Critical revision of the manuscript for important intellectual content: Douville, Myers, and Jackson. Statistical analysis: Myers. Administrative, technical, and material support: Lantos. Study supervision: Jackson and Lantos.

Financial Disclosure: None reported.

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