Recommendations for research
The guideline committee has made the following recommendations for research.
What are the important messages and how should they be tailored and delivered to encourage and sustain flu vaccination uptake in eligible groups?
There is limited qualitative, effectiveness and cost-effectiveness evidence about what is effective in increasing flu vaccination in most eligible groups. In particular, we need to know how to tailor and deliver messages, for example, to minority ethnic communities, who may have lower vaccination uptake and also be disproportionately affected by some chronic conditions that put them at greater clinical risk from flu. A key to this is understanding how to engage people, including children and young people, and how they want to be involved in decision-making. This might include carers and other decision-makers. Interventions may need to be specifically targeted for different groups, so there is a need to understand individual and cultural health beliefs underpinning decisions about vaccination. Evidence indicates that beliefs about flu vaccination (such as effectiveness and side effects) are a persistent barrier. Understanding the key messages and the best format to deliver them in (for example, using social media or other forms of electronic communication) to reach different groups will help to overcome these barriers. This will increase the precision with which commissioners and intervention developers can engage eligible groups and increase rates of flu vaccination.
What are the most effective and cost-effective ways of reaching underserved groups and removing barriers to access in order to increase their uptake of flu vaccination?
The evidence reviewed did not provide specific details about the needs of people in underserved groups. Particularly important are those people who may be disproportionately affected by chronic conditions that increase their risk of complications from flu and who may have unique barriers to accessing flu vaccination (for example, they may have an undiagnosed clinical condition and not recognise that they are eligible for free flu vaccination, or they may not be registered with a general practice). They may also be difficult to identify. Research is needed into the specific needs, barriers and facilitators of eligible people in underserved groups. This should include how and what is effective in improving access, raising awareness, and offering and delivering vaccination. This will enable commissioners and those with responsibility for flu vaccination delivery to develop interventions to reach these groups.
In what context is it cost effective to increase uptake of flu vaccination among carers?
There is a lack of peer-reviewed evidence on what is effective and cost effective in increasing flu vaccination in carers. This key target group can be difficult to identify, and people who provide care may not always identify themselves as carers. The limited evidence suggests it is not cost effective to increase uptake of vaccination in all carers. Better understanding is needed about the effect of increasing vaccination in carers on rates of flu transmission, and the wider social and economic benefits to the health and social care system. Research is needed on the need for targeting, how this should be done and which cared-for groups are most important. Evidence about the effect on uptake of increasing the identification and offer of vaccination to carers through opportunistic engagement in all settings would enable more specific recommendations to be made. It would also allow further assessment of the economic benefits. Evidence about why a carer would choose not to be vaccinated will also improve understanding and inform recommendations and intervention development.
Are opt-out strategies effective and cost effective at increasing uptake of flu vaccination among front-line health and social care staff?
The evidence indicated that mandatory flu vaccination and the use of declination policies, either as a single intervention or part of a multicomponent approach, had a large and consistent effect in increasing vaccination uptake among health and social care staff in non-UK settings. However there are potential barriers to this in the UK; in particular, the possible negative impact on employee morale, which has also been seen in qualitative studies from other countries. The committee felt that similar increases in flu vaccination may be achievable using an opt‑out strategy. But to clarify the potential of this intervention, empirical evidence is needed on whether it is more effective and cost effective than other successful approaches for promoting uptake of flu vaccination among front-line health and social care staff in different UK settings, and what barriers and facilitators there are to its implementation from the perspective of providers and recipients; in particular, attitudes to the feasibility and acceptability of an 'opt‑out' flu vaccination strategy.
What models of community-based flu vaccination provision (for example, community pharmacies, community nursing and midwifery teams and outreach services) are effective and cost-effective for increasing uptake in eligible groups?
There is high variability across England in rates of flu vaccination uptake in eligible groups. Little is known about the effectiveness and cost effectiveness of extending community-based provision to include, for example, community pharmacies, community nursing and midwifery teams and outreach services into a variety of settings. Expert testimony suggested that community outreach interventions are effective for underserved groups such as people who are homeless, but empirical evidence for the effectiveness and cost effectiveness of such interventions is lacking. Limited evidence to date suggests that community pharmacy provision of NHS flu vaccinations has displaced rather than increased overall vaccination activity, because community pharmacies may be more convenient for some people in eligible groups. As new services become better publicised and embedded, there is a need to know if they are good value for money and whether (and why) they increase uptake. More research is needed on alternative models of community-based provision to inform future interventions and recommendations, particularly if it reaches groups who are currently underserved, and who may not use traditional routes such as GP services.