PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Vaccine. Author manuscript; available in PMC 2010 July 9.
Published in final edited form as:
PMCID: PMC2700851
NIHMSID: NIHMS113569

Alternative Vaccination Locations: Who Uses Them and Can They Increase Flu Vaccination Rates?

Bruce Y. Lee, MD, MBA,1,2 Ateev Mehrotra, MD, MPH,1,3 Rachel M. Burns, MPH,3 and Katherine M. Harris, PhD3

Abstract

Since many unvaccinated individuals do not regularly contact the traditional health care system, we sought to determine the role that alternative vaccination locations (e.g., workplaces and retail clinics) could play in increasing influenza vaccination coverage. Between February 14, 2008 and March 10, 2008, a 25-question influenza vaccine questionnaire was administered to a nationally representative, stratified sample of panelists. Our result found that while alternative locations are covering some segments not captured by the traditional health care system (e.g., younger, working, white individuals in metropolitan areas), they are not serving many other segments (e.g., minority, rural, or lower income patients).

INTRODUCTION

Despite the demonstrated benefits of influenza vaccine, [113] each year a large percentage of adults go unvaccinated.[14, 15] Efforts aimed at increasing influenza vaccine coverage have focused primarily on increasing vaccination in physicians’ offices (e.g., computer reminders, standing order sets, advertising campaigns)[1624] but these efforts may have diminishing returns. Working individuals or those without any other reason to see a physician may be less willing to endure the inconvenience of making an appointment in advance and the associated work absence, travel and wait time with an appointment.[25] Alternative locations (e.g., retail stores and workplaces, could be increasingly viable because of the increasing number of retail clinics (health clinics located in retail stores that are staffed primarily by nurse practitioners) and prevalence of influenza immunization at worksites.[2630]

Our study used data from a nationally representative survey of US adults from the 2007–2008 influenza season to better understand the potential for these alternative locations (retail clinics or worksites) to improve influenza vaccination rates. Our goals were to (1) describe the characteristics of patients who did not receive the influenza vaccine and determine the fraction of those in this group who had little contact with the medical system and therefore could benefit from an alternative location, (2) determine where vaccinated patients received the influenza vaccine (i.e., traditional health care location vs. alternative locations) and the characteristics of patients who were vaccinated at different locations, and (3) compare the characteristics of unvaccinated patients with those using alternative locations. Such comparisons can help identify whether alternative locations are serving populations that are not being vaccinated at traditional health care sites.

METHODS

Sample Design

We analyzed responses drawn from a nationally representative, stratified sample of panelists recruited by Knowledge Networks (KN) fielded between February 14, 2008 and March 10, 2008. This panel has been used for many previous research studies.[3134] KN recruited panelists using random digit dialing (RDD) methods and administers surveys on a variety of topics to panelists via the internet in exchange for small financial incentives. KN provides Web-TV hardware, software, and training to households without computers. Telephone exchanges with higher fractions of African-Americans and Hispanics and elderly were oversampled. Sample weighting adjusted for potential biases such as survey non-coverage and non-response.

Measures

The 25-question questionnaire consisted of 5 major sections: receipt of influenza vaccine during the past influenza season, experiences talking to health care providers about vaccines, information and views about vaccines, demographic information, and information about health care utilization and health status.

Data Analysis

Our analysis separated patients into patients high-risk versus low-risk for influenza and patients with and without a regular health care provider. High-risk was defined using the following Centers for Disease Control and Prevention (CDC) criteria: age greater than 50 years old, significant co-morbidities, or living or working with high-risk patients. We defined patients who did not have a regular health care provider as those who indicated that they did not have a regular health care provider or did not see a physician in the previous 12 months.

Statistical analyses were conducted using STATA 10 (Statacorp, College Station, Texas) and SAS 9.1 (SAS Institute, Cary, North Carolina). Differences were considered statistically significant at a p-value less than 0.05.

RESULTS

The survey was sent to 4,458 panelists aged between 18 and over. A total of 3,043 (68 percent) panelists responded. Table 1 shows the distribution of completed surveys by ethnic and age groups. All analyses were sample-weighted in order to draw nationally representative inferences.

TABLE 1
Sample Characteristics (unweighted n=3043)

Characteristics of Patients Who Did Not Receive the Influenza Vaccine

Respondents who were over 50 years old, college-educated, employed, white, chronically ill, and considered CDC high risk and has a personal physician, a longer relationship with the physician, and more physician visits were significantly more likely (p<0.05) to have been vaccinated (Table 2).

TABLE 2
TABLE 2: Characteristics of individuals who received the vaccine

Influenza Vaccination Location

Of patients who received the influenza vaccine, 68.4 percent received the vaccine at a traditional health care location (i.e., physician’s office, hospital, or public health clinic), 22.5 percent received the vaccine at work, and 9.1 percent received it at a retail store such as a pharmacy or grocery store. Multivariate analyses (Table 3) showed that respondents who used traditional health care locations were significantly (p≤0.05) more likely to be unemployed, not white and not African American, living in an urban (vs. rural) area, located in the Northeast, Midwest, or South, and to indicate that convenience was an important factor in deciding whether to get vaccinated. Compared to those vaccinated at traditional health care locations, respondents vaccinated at work were significantly (p≤0.05) more likely to live in the South, have an employer who requires influenza vaccination, and to indicate that convenience was an important factor in deciding whether to get vaccinated. Compared to those vaccinated at traditional health care locations, respondents vaccinated at a retail store were significantly (p≤0.05) more likely to be over 50 years of age, non-white, located in the Northeast or Midwest United States, have a designated physician, have had more than one physician visit over the prior year, and considered high risk for influenza. The p-value for living in an urban area was 0.0502. Those vaccinated at a retail store were more likely to be unsure about how many physician visits they had over the prior year.

TABLE 3
Predicting the Likelihood of Receiving an Influenza vaccination at a Traditional Location, a Retail Clinic, or the Workplace among vaccinated individuals: Multivariate Results.

DISCUSSION

Our survey was primarily designed to look at national influenza vaccine coverage rates with oversampling of racial minorities and subpopulations covered by the CDC/Advisory Committee on Immunization Practices influenza vaccine recommendations. As described previously, our survey appears comparable to the National Health Interview Survey (NHIS) with some added advantages of being influenza vaccination-focused and Internet-based: more rapid data collection, analysis, and modification to accommodate questions about emerging topics (e.g., vaccination in non-traditional settings) or key subgroups (e.g., employed versus non-employed).[35] Our study has limitations inherent in single year survey-based studies: e.g., recall and response bias, extrapolating sample results to the entire population, potential misunderstanding of questions, and a single year may not represent other years. Additionally, RDD recruitment will miss individuals without telephones, and an Internet-based survey may still deter those not comfortable with such technology, despite active instruction.

Consistent with other sources, our results demonstrate that many individuals, including a large number of those considered high-risk, go unvaccinated each year.[3638] Thirty-one percent of unvaccinated respondents did not have regular contact with a health care provider (i.e., no physician visits and no personal doctor). Can alternative locations, such as workplaces and retail stores, be an effective means to improve vaccination rates? We believe yes, with some important caveats.

Alternative locations address some population segments not captured by the traditional health care system. Retail stores capture patients who are older, non-white, and high-risk for influenza. Workplaces appeal to those who value convenience in the vaccination decision. Nonetheless alternative locations are not serving many other population segments (e.g., rural or lower income patients) that do not regularly interact with the traditional health care system. In fact, retail stores are serving many individuals who have had multiple physician visits over the prior year.

It is possible that alternative locations can better serve these missed segments. Future studies may explore whether workplaces with lower income or rural employees have influenza vaccination programs. It also may be helpful to look at whether retail stores in rural or non-white communities are offering the influenza vaccine.[37, 3942] Subsequent studies could take a closer look at the location, advertising, marketing, and staff composition of alternative locations and how these characteristics affect the types of patients who access these locations.

Acknowledgments

Acknowledgements and Disclaimers: The survey data was collected under a contract with GlaxoSmithKline. The sponsor had no role in the research design or in the preparation, review, or approval of the document. The study design, data management, analysis and opinions expressed here are solely those of the authors and do not represent those of RAND or GlaxoSmithKline.

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

References

1. Influenza and pneumococcal vaccination rates among persons with diabetes mellitus--United States, 1997. MMWR Morb Mortal Wkly Rep. 1999 Oct 29;48(42):961–7. [PubMed]
2. Arden N, Monto AS, Ohmit SE. Vaccine use and the risk of outbreaks in a sample of nursing homes during an influenza epidemic. Am J Public Health. 1995 Mar;85(3):399–401. [PubMed]
3. Fiore AE, Shay DK, Haber P, Iskander JK, Uyeki TM, Mootrey G, et al. Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2007. MMWR Recomm Rep. 2007 Jul 13;56(RR6):1–54. [PubMed]
4. Hayden FG. Prevention and treatment of influenza in immunocompromised patients. Am J Med. 1997 Mar 17;102(3A):55–60. discussion 75–6. [PubMed]
5. Ison MG, Sharma A, Shepard JA, Wain JC, Ginns LC. Outcome of influenza infection managed with oseltamivir in lung transplant recipients. J Heart Lung Transplant. 2008 Mar;27(3):282–8. [PubMed]
6. Nichols WG, Guthrie KA, Corey L, Boeckh M. Influenza infections after hematopoietic stem cell transplantation: risk factors, mortality, and the effect of antiviral therapy. Clin Infect Dis. 2004 Nov 1;39(9):1300–6. [PubMed]
7. Piedra PA, Gaglani MJ, Kozinetz CA, Herschler G, Riggs M, Griffith M, et al. Herd immunity in adults against influenza-related illnesses with use of the trivalent-live attenuated influenza vaccine (CAIV-T) in children. Vaccine. 2005 Feb 18;23(13):1540–8. [PubMed]
8. Reichert TA, Simonsen L, Sharma A, Pardo SA, Fedson DS, Miller MA. Influenza and the winter increase in mortality in the United States, 1959–1999. Am J Epidemiol. 2004 Sep 1;160(5):492–502. [PubMed]
9. Sandoval C, Walter SD, Krueger P, Smieja M, Smith A, Yusuf S, et al. Risk of hospitalization during influenza season among a cohort of patients with congestive heart failure. Epidemiol Infect. 2007 May;135(4):574–82. [PubMed]
10. Schwartz B, Hinman A, Abramson J, Strikas RA, Allred N, Uyeki T, et al. Universal influenza vaccination in the United States: are we ready? Report of a meeting. J Infect Dis. 2006 Nov 1;194( Suppl 2):S147–54. [PubMed]
11. Thompson WW, Shay DK, Weintraub E, Brammer L, Cox N, Anderson LJ, et al. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA. 2003 Jan 8;289(2):179–86. [PubMed]
12. Upshur RE, Goel V. Measuring the impact of influenza on the hospital admission rates of the elderly in Ontario: a five-year admission rate analysis, 1988–1993. Can J Public Health. 2000 Mar–Apr;91(2):144–7. [PubMed]
13. Wongsurakiat P, Maranetra KN, Wasi C, Kositanont U, Dejsomritrutai W, Charoenratanakul S. Acute respiratory illness in patients with COPD and the effectiveness of influenza vaccination: a randomized controlled study. Chest. 2004 Jun;125(6):2011–20. [PubMed]
14. State-specific influenza vaccination coverage among adults aged > or =18 years--United States, 2003–04 and 2005–06 influenza seasons. MMWR Morb Mortal Wkly Rep. 2007 Sep 21;56(37):953–9. [PubMed]
15. Influenza and pneumococcal vaccination coverage among persons aged > or = 65 years--United States, 2004–2005. MMWR Morb Mortal Wkly Rep. 2006 Oct 6;55(39):1065–8. [PubMed]
16. Nichol KL, Zimmerman R. Generalist and subspecialist physicians’ knowledge, attitudes, and practices regarding influenza and pneumococcal vaccinations for elderly and other high-risk patients: a nationwide survey. Arch Intern Med. 2001 Dec 10–24;161(22):2702–8. [PubMed]
17. Stone EG, Morton SC, Hulscher ME, Maglione MA, Roth EA, Grimshaw JM, et al. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med. 2002 May 7;136(9):641–51. [PubMed]
18. Nichol KL. Ten-year durability and success of an organized program to increase influenza and pneumococcal vaccination rates among high-risk adults. Am J Med. 1998 Nov;105(5):385–92. [PubMed]
19. Dexter PR, Perkins SM, Maharry KS, Jones K, McDonald CJ. Inpatient computer-based standing orders vs physician reminders to increase influenza and pneumococcal vaccination rates: a randomized trial. JAMA. 2004 Nov 17;292(19):2366–71. [PubMed]
20. Barton MB, Schoenbaum SC. Improving influenza vaccination performance in an HMO setting: the use of computer-generated reminders and peer comparison feedback. Am J Public Health. 1990 May;80(5):534–6. [PubMed]
21. Bertin M, Scarpelli M, Proctor AW, Sharp J, Robitson E, Donnelly T, et al. Novel use of the intranet to document health care personnel participation in a mandatory influenza vaccination reporting program. Am J Infect Control. 2007 Feb;35(1):33–7. [PubMed]
22. Ogburn T, Espey EL, Contreras V, Arroyo P. Impact of clinic interventions on the rate of influenza vaccination in pregnant women. J Reprod Med. 2007 Sep;52(9):753–6. [PubMed]
23. Reynolds CE, Snow V, Qaseem A, Verbonitz L. Improving immunization rates: initial results from a team-based, systems change approach. Am J Med Qual. 2008 May–Jun;23(3):176–83. [PubMed]
24. Shenson D, Adams M, Bolen J. Delivery of preventive services to adults aged 50–64: monitoring performance using a composite measure, 1997–2004. J Gen Intern Med. 2008 Jun;23(6):733–40. [PMC free article] [PubMed]
25. Harpole LH, Orav EJ, Hickey M, Posther KE, Brennan TA. Patient satisfaction in the ambulatory setting. Influence of data collection methods and sociodemographic factors. J Gen Intern Med. 1996 Jul;11(7):431–4. [PubMed]
26. Mehrotra A, Wang MC, Adams JL, Lave JR, McGlynn EA. A Comparison of Patient Visits to Retail Clinics, Primary Care Physicians, and Emergency Departments. Health Affairs. 2008 In press. [PMC free article] [PubMed]
27. Scott MK. Health Care in the Express Lane: Retail Clinics Go Mainstream. Oakland, CA: California HealthCare Foundation; 2007.
28. Mehrotra A, Wang MC, Lave JR, Adams JL, McGlynn EA. Retail clinics, primary care physicians, and emergency departments: a comparison of patients’ visits. Health Aff (Millwood) 2008 Sep–Oct;27(5):1272–82. [PMC free article] [PubMed]
29. Gopal S, Davis MM. Delivery of influenza vaccine to non-elderly persons with cardiovascular disease, with varying national supply of vaccine: a decision analysis. Hum Vaccin. 2005 Nov–Dec;1(6):217–23. [PubMed]
30. Poel AJ, Singleton JA, Wooten K. Where adults reported receiving influenza vaccination, US, 1998/1999. 35th National Immunization Conference; Atlanta, GA: Centers for Disease Control and Prevention; 2001.
31. Knowledge Netowrks Bibliography: Articles and Presentations Based on KN Collected Panel Data, Analysis, or Methodology. 2007. [cited 2008 October 5]; Available from: http://www.knowledgenetworks.com/ganp/docs/KN%20Bibliog%205-29-2007%20External.pdf.
32. Baker L, Wagner TH, Singer S, Bundorf MK. Use of the Internet and e-mail for health care information: results from a national survey. JAMA. 2003 May 14;289(18):2400–6. [PubMed]
33. Rigby AJ, Ma J, Stafford RS. Women’s awareness and knowledge of hormone therapy post-Women’s Health Initiative. Menopause. 2007 Sep–Oct;14(5):853–8. [PubMed]
34. Harris KM. How do patients choose physicians? Evidence from a national survey of enrollees in employment-related health plans. Health Serv Res. 2003 Apr;38(2):711–32. [PMC free article] [PubMed]
35. Harris KM, Schonlau M, Lurie N. Surveying a nationally representative internet-based panel to obtain timely estimates of influenza vaccination rates. Vaccine. 2009 Feb 5;27(6):815–8. [PubMed]
36. Influenza vaccination coverage among persons with asthma--United States, 2005–06 influenza season. MMWR Morb Mortal Wkly Rep. 2008 Jun 20;57(24):653–7. [PubMed]
37. Lu P, Bridges CB, Euler GL, Singleton JA. Influenza vaccination of recommended adult populations, U.S., 1989–2005. Vaccine. 2008 Mar 25;26(14):1786–93. [PubMed]
38. Singleton JA, Santibanez TA, Wortley PM. Influenza and pneumococcal vaccination of adults aged > or = 65: racial/ethnic differences. Am J Prev Med. 2005 Dec;29(5):412–20. [PubMed]
39. Marin MG, Johanson WG, Jr, Salas-Lopez D. Influenza vaccination among minority populations in the United States. Prev Med. 2002 Feb;34(2):235–41. [PubMed]
40. Fiscella K, Franks P, Doescher MP, Saver BG. Disparities in health care by race, ethnicity, and language among the insured: findings from a national sample. Med Care. 2002 Jan;40(1):52–9. [PubMed]
41. Fiscella K, Dressler R, Meldrum S, Holt K. Impact of influenza vaccination disparities on elderly mortality in the United States. Prev Med. 2007 Jul;45(1):83–7. [PubMed]
42. O’Malley AS, Forrest CB. Immunization disparities in older Americans: determinants and future research needs. Am J Prev Med. 2006 Aug;31(2):150–8. [PubMed]