Results

A total of 551/747 (73.8%) patients receiving influenza vaccines between September and the end of December 1996 returned completed questionnaires. Over half of them (321/549, data missing for two patients) were female. Most respondents, 67% (392/509, data missing for 42), were aged 65 years or over, and most (90.6%; 461/509, data missing for 42) were receiving a repeat influenza vaccination. Only 4.5% of respondents (20/442, data missing for 109) stated that they had received pneumococcal vaccine previously. Less than half the respondents (44.1%, 243/551) considered themselves to be in an at-risk group. Table 1 shows the risk groups that vaccinees identified. A number of patients identified themselves as being in two (7%; 38/551) or three (1%; 6/551) risk groups. An analysis of records of a randomly selected sample of respondents showed that more patients (50.9%; 55/108) were actually in a risk group than identified themselves as such in the questionnaire (table 2). Most patients who were at risk were correct in self-identifying that risk (71%; 39/55).

A quarter (26.1%) of respondents (133/509, data missing for 42) stated that they had heard of pneumococcal vaccine. Table 3 shows the sources that they had heard about it from. Thirteen patients had heard about it from two sources and three patients stated three sources.

Attitudes to vaccination were generally positive. Positive statements, that is those more likely to encourage vaccination, were recoded so that a score greater than three meant a generally positive attitude, a score of three neutral and a score less than three signified an overall negative attitude towards vaccination. Responses to each attitude statement and mean scores are shown in table 4. A total attitude score was derived for each patient by combining their scores for each statement after recoding positive statements. A higher score meant a more positive attitude. Patients who identified themselves to be in a risk group were significantly more likely to have a positive attitude towards vaccinations than those who did not recognise themselves to be in a risk group (total score 32.9 vs 36.8; Kruskal-Wallis H = 72.1, 1 degree of freedom (df), p<0.001). Patients who stated that they had previously heard about pneumococcal vaccination were also more positive towards vaccination (total score 36.9 vs 34.0; Kruskal-Wallis H = 28.2, 1 df, p<0.001). Patients who identified themselves to be in a risk group were significantly more like to agree or strongly agree that they would like pneumococcal vaccine than those who did not (145/238 (60.9%)vs 113/300 (37.7%); χ² = 46.1, 4 df, p<0.001). Patients who had already attended for pneumococcal vaccine were significantly more likely to agree or strongly agree that they would like pneumococcal vaccine than those who did not (16/19 (84.2%) vs 198/418 (47.4%); χ² = 12.1, 4 df, p = 0.017).

A targeted vaccination campaign over one year resulted in the following proportions of patients in at-risk groups being vaccinated: 144 patients with coronary disease out of a total of 312 patients in the practice (46%); diabetes 79/132 (60%); splenectomy 2/2 (100%); chronic obstructive airways disease and asthma 135/700 (19%); chronic renal failure 5/9 (56%). Only the splenectomy patients had been vaccinated prior to the campaign. Most doses of pneumococcal vaccine (336/463; 73%) were delivered to patients in high-risk groups. This figure increased to 365/463 (79%) when nursing home patients without other risk factors were included.

Discussion

The current guidelines for pneumococcal vaccination recommend vaccination at routine consultations, after discharge from hospital, and when immunising against influenza vaccination. This study looked at this strategy as a method of targeting uptake of pneumococcal vaccination to patients in risk groups in one general practice. It is likely that the survey results are valid for this practice given the response rate of 73.8%. Further study would be required before the results could be extrapolated to other practices with a different age structure, case-mix, availability of resources (for example, practice nurses, district nurses, refrigerators for storage, treatment rooms), etc.

Overall, about half the patients receiving influenza vaccination were in a risk group, mostly chronic chest or heart disease and diabetes, and so were eligible for pneumococcal vaccination. Although one could argue that this shows that the practice policy for influenza vaccination does not fit well with current Department of Health guidance, it may also reflect practical problems with the current guidelines. Although influenza vaccination is recommended for those with specific medical indications and institutionalised patients, the evidence supports vaccinating all patients aged over 6514and possibly even all healthy adults.15 The Department of Health has recently extended its policy to include patients over 75 years16 and some authors have advocated expanding vaccination against influenza and pneumococcus to all those above the age of 65 years17 as recommended in the US, where Medicare funds influenza vaccine for all patients over 65 years and has demonstrated this to be a cost-effective use of resources,18 19 and by the World Health Organization.20 With the considerable financial penalties for practices who purchase but do not use vaccine, there is justifiable scope for more lax interpretation of the guidelines based on the evidence and clinical judgement. Nevertheless, almost half (49.1%) the patients in this study undergoing influenza vaccination did not fall into a current Department of Health risk group. Similar results were found in Gwent with only a quarter of all influenza vaccine doses being given to patients at low risk.21 A review of the UK guidelines, aligning those for pneumococcal and influenza vaccination and including all patients over 65 years, would improve the logistics of vaccine delivery and thereby vaccine uptake.

Attitude towards vaccination, self-identification as high risk and intention to be immunised have been shown to predict subsequent uptake.8 Subgroup analysis of responses in our study showed that patients in at-risk groups had more positive attitudes to vaccination, in particular pneumococcal vaccination, than those who were not in a risk group. Patients with more positive attitudes to vaccination and preventive health were more likely to agree to having pneumococcal vaccination than those who were not in a risk group. As patients were fairly good at identifying whether they were at risk, targeting patients who are being immunised for influenza would seem to be a good method for getting initial coverage of pneumococcal vaccination in general practice and was an effective part of our strategy.

Patients with chronic lung disease and asthma, who comprised the largest risk group, had the lowest uptake of the groups being surveyed. This may have been due in part to the inclusion in this large group of many younger and ‘inactive’ asthmatics (ie, patients who had asthma in the past but were now asymptomatic and off treatment), not attending for influenza vaccine. There is also some confusion as to whether asthma constitutes a high-risk group for pneumococcal vaccination as it is for influenza vaccination.22 The patients who are eligible for influenza and pneumococcal vaccine in this group will need better identification and targeting if we are to improve vaccine uptake rates.

Studies have shown that recommendation for vaccination by a health worker is the most important factor influencing uptake23and agreeing a practice policy has also been shown to improve uptake.7 We found the practice guideline to be a useful educational tool, enabling a clear message to be given to patients by doctors and nurses. A poster display all year round, expanded to coincide with the influenza campaign, increased patient awareness of the vaccine. Vaccination reminders on records, prescriptions or appointment lists4 are other methods that could have been but were not used in this study.

The difficulties in running this type of programme were similar to those for running any successful immunisation programme, and included identifying and targeting eligible patients for which one needs a good, preferably computerised, chronic disease register. Correctly estimating vaccine requirements, good stock control, and suitable storage of vaccines were vital. Nursing and medical time to inform and vaccinate patients required good organisation of available nursing time and sufficient nursing hours. On the plus side we were able to generate an income of £6.46 per vaccine,* demonstrate good risk management (particularly in vaccinating splenectomised patients), and improve preventive care for many of our patients.

Clinical audit of immunisation rates is likely to be an effective and acceptable way of improving and monitoring vaccine uptake. The audit of immunisation rates conducted in this study showed a good uptake in high-risk groups but would have tended to overestimate uptake because of denominator deficiencies.

In the US, the Surgeon General has set a target of vaccinating 60% of the elderly and high-risk patients with pneumococcal vaccine by the year 2000.24 Although similar targets have not been set by the Department of Health, they may be useful in improving rates and may not be unrealistic, given the experience in this practice. Pneumococcal vaccination has been shown to be a cost-effective medical intervention.25 Further studies may be needed to determine what proportion of at-risk patients currently take up pneumococcal vaccination and how to maximise uptake of pneumococcal vaccine in primary care.