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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Vaccine. Author manuscript; available in PMC 2014 January 2.
Published in final edited form as:
PMCID: PMC3529783

Correlates of seasonal flu vaccination among U.S. home health aides

Alberto J. Caban-Martinez, DO, PhD, MPH, CPH,1 Anna Arlinghaus, Dipl-Psych, PhD,1,2 and Silje E. Reme, PsyD, PhD1


In the United States, home health aides include a group of paraprofessionals that provide direct health care services such as changing bandages and dressing wounds, as well as delivering medications to the elderly, convalescents, or individuals with disabilities either at the patient's home or in a residential care facility [1]. These workers also provide personal care such as bathing, dressing, and grooming as required by the patient [1]. Despite their direct and close proximity to vulnerable and sick populations, many of these workers receive very little education about infectious disease control and vaccination [23]. Given the U.S. is experiencing an increasingly aging population and a shift in patient care to non-hospital settings [4], there will likely be an increase in demand for this health worker population and a need to understand their vaccination practices.

Current U.S. national studies on seasonal flu vaccination prevalence rates indicate that among U.S. healthcare workers, vaccination remains low at 44.8% with individuals employed as health diagnosing and treating practitioners having the highest rates (52.3%), and other healthcare support occupations (e.g. Birth Attendants, Morgue Attendants, Phlebotomists, Patient Transporters) having the lowest (32.0%). In the same study, seasonal flu vaccination rates were highest for white collar workers other than healthcare workers (24.7%), and lowest for farm workers (11.7%) [5]. These sustained low immunization rates in the U.S. healthcare workforce are perplexing, given that (1) Medicaid in most States provides subsidy for influenza vaccine, (2) evidence for influenza vaccine being efficacious, and (3) systematic reviews of effective methods to increase immunization rates have been well documented [4,6]. Evidence from tailored interventions to increase seasonal influenza vaccination suggests that each individual and agency has their own values and internal structures that influence vaccination rates [6].

As the number of home health aide professionals increases in the United States, understanding seasonal flu vaccination rates within this workforce is paramount. In the present study we sought to describe seasonal flu vaccination rates in a nationally representative sample of U.S. home health aides and examine correlates for receipt of flu vaccination to inform the development of a tailored vaccination intervention among home health aides.


Data Source and Sample

The 2007 National Home Health Aide Survey (NHHAS) conducted by the National Center for Health Statistics includes the first nationally representative sample of U.S. home health aides with information on job characteristics, family life, client relations, organizational commitment and job satisfaction, workplace environment, work-related injuries, and demographics [7].

Home health aides employed by agencies that provided home health and/or hospice care were identified and selected through a complex, multistage sampling probability design. A total of 3,377 interviews of aides working in agencies providing home health and/or hospice care completed a computer-assisted telephone interviewing system to collect the survey data. The unweighted response rate among persons in the sample was 79% (3,377/4,279) [7].


Influenza vaccination status was assessed in the NHHAS interview by response to the question: “During the past 12 months, have you received a flu shot?” Aides were asked to specify their job title, including home health aide, home care aide, hospice aide, personal care attendant, or other licensed nursing assistant. The category of “other licensed nursing assistants” includes health aides that have formal licensed training and provide basic patient care such as feeding, bathing, dressing, grooming, or moving patients under direction of nursing staff [1]. We operationalized self-reported socio-demographic variables as follows: age (under 25 years; 25–34 years old; 35–44 years old; 45–54 years old; and 55 years and older), gender (male/female), race (White, Black, and Other), Hispanic ethnicity (Hispanic/non-Hispanic), educational attainment (less than a high school diploma; graduated high school/attained GED; attended college or technical school; or graduated college or technical school); marital status (married/living with a partner; divorced, widowed, separated; or single), family income (less than $20,000; $20,000–$29,000; $30,000–$39,000; $40,000–49,000; $50,000 or more), primary language (English/Spanish or Other); and health insurance status (yes/no). Health insurance status was operationalized from respondents answering in the affirmative to one of the following two survey questions: 1) “Are you currently participating in health insurance plan available from {AGENCY}?”; or 2) “Covered by other plan; covered by Medicare or Medicaid or other government insurance?”.

Data Analysis

Given the complex sample survey design of the NHHAS, descriptive statistics and univariable and multivariable logistic regression models were calculated with the SPSS 19 (IBM Co, Chicago, IL) Complex Sample module to take into account sample weights and design effects. The protocol was approved by the institutional review board of the Harvard School of Public Health.


There were a total of 3,377 survey participants 20 years and older who reported working as a home health aide in the 2007 NHHAS (representing an estimated 160,720 U.S. home health aides; Table 1). The overall prevalence of reported influenza vaccination for all home health aides during the survey period was 43.9%. The prevalence of reported influenza vaccination among all health aides was highest among other licensed nursing assistants (68.2%), and lowest among home health aides (41.3%). For all home health aides, influenza vaccination rates were lowest for aides aged 35–44 years old (36.7%), male (40.7%), Black (34.5%), Hispanic (43.1%), less than a high school education (32.6%), never married (38.6%), less than $20,000 in family income (41.5%), without health insurance (33.9%), and non-native English speaker (40.1%).

Table 1
Seasonal Influenza Vaccination Coverage Estimates in US Home Health Aides by Occupation Type and Socio-demographic Correlates: the 2007 U.S. National Home Health Aide Survey

In the multivariable model (Table 2), self-reported flu vaccination was significantly associated with all health aide occupations, including home health, home care, hospice, and personal care attendant (Adjusted odds ratio, AOR =0.42; 95% CI [0.20–0.85], 0.41;[0.17–0.99], 0.50;[0.26–0.97], 0.53;[0.26–0.99]) when compared to other licensed nursing assistants. Additionally, Black health aides vs. White (AOR= 0.56 [0.33–0.94]) and those without health insurance vs. with health insurance (AOR= 0.63 [0.40–0.99]) were significantly less likely to report receiving a flu shot.

Table 2
Univariable and Multivariable Logistic Regression of self report of Seasonal Flu Vaccination Among Home Health Aides: the 2007 U.S. National Home Health Aide Survey


We found the prevalence of flu vaccination among all U.S. health aides to be low overall (44%), with aides employed in home health and home care occupations reporting the lowest rate of influenza vaccination. Findings from the present study are consistent with other national self-report influenza vaccination receipt studies where self-reported flu shot rates were low among all U.S. health care providers including health aides [5,89]. We also found health aides of Black race were significantly less likely to report receipt of a seasonal flu vaccine as compared to their White health aide counterpart. Racial and ethnic disparities in vaccination rates in the general population are not a new finding [11], however somewhat surprising for the home health aide workforce given one would expect the rates for this paraprofessional workforce to be at least similar across race and ethnicity due to their healthcare training, albeit limited. Uninsured health aides were also significantly less likely to report flu vaccination as compared to those with health insurance.

The aging U.S. population and changes in the health care delivery system are likely to increase the demand for health aides in various short and long-term health settings including private homes. Currently there are few and often brief training programs for home health aides that may not provide sufficient training in infectious disease control, sanitation and hygiene, all of which are skills critical to patient care particularly among vulnerable populations such as the elderly [10]. Developing targeted effective vaccination campaigns among specific health aide worker groups are needed to improve vaccination rates among home health aides.

The NHHAS is limited by the self-reported nature of the respondent’s flu vaccination status; however, previous studies have shown the sensitivity and specificity of self-reported adult influenza vaccination to be reliable measures [12]. Additionally, due to the cross-sectional nature of the NHHAS, no temporal causality could be examined. The 2007 NHHAS data is slightly dated however previous studies using other national datasets for flu vaccination rates [5] suggests that these trends are consistent over time with similar healthcare occupations. Another limitation is the homogeneity of the sample, which leads to a lack of variance in the assumed predicting factors and, therefore, to a higher probability of statistically not significant results. Despite these limitations, the ability to use large sample sizes, the nationally representative nature of the database and the timely assessment make these NHHAS data uniquely useful for assessing the prevalence of flu vaccination by U.S. home health aides, including specific health aide subpopulations. Health education programs on the availability, cost, effectiveness and safety of the influenza vaccine (as well as other issues of protection and prevention of influenza transmission and exposure) are critical to the health and protection of the home health aides themselves, as well as their respective patients and communities [13]. Agencies employing home health and/or hospice aides may consider developing tailored health education programs and providing flu vaccination resources to their employees.


The authors would like to thank the statisticians and scientists at the National Center for Health Statistics for their assistant with the survey’s complex sampling scheme: Dr. Lauren D. Harris-Kojetin, Dr. Christine Caffrey, and Dr. Roberto Valverde. The authors also acknowledge the consultation of Dr. Miguel Marino from the Department of Biostatistics at the Harvard School of Public Health.


Funding support to accomplish the research was largely supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) grant T32 AR055885 (PI: Katz) to the Clinical Orthopedic and Musculoskeletal Education and Training (COMET) Program at Brigham and Women’s Hospital, Harvard Medical School and Harvard School of Public Health (Trainee: Dr. Caban-Martinez) and the Harvard School of Public Health – Liberty Mutual Research Institute for Safety Postdoctoral Research Fellowship program (Trainees: Dr. Arlinghaus and Dr. Reme).


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.


The authors wish to express that they have no financial or other relationships that might lead to a conflict of interest.


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