Can primary care physician recommendation improve influenza vaccine uptake among older adults? A community health centre-based experimental study in China

Influenza is a highly-infected disease that can cause severe illnesses and even deaths [1]. Older adults, especially those with underlying diseases, are at a higher risk of being infected with or dying from influenza [2, 3]. Vaccination is the most effective way to protect against influenza [4]. Existing evidence suggests that influenza vaccine uptakes can reduce the severity level of physical conditions [5] and prevent influenza-related hospitalizations and deaths among older adults [6‐8]. In developed countries, the rates of influenza vaccination among older adults are relatively high, for instance, 79.0% in the United Kingdom and 75.2% in the United States [9, 10].

In contrast, the coverage of influenza vaccination in China remains relatively low-only 3.8% of the older participants were vaccinated in a national survey study during the 2018–2019 flu season [11]. Prior studies indicated that provider-level barriers and a lack of willingness to take influenza vaccines among populations contributed to the low vaccination coverage in China [12, 13]. On one hand, the knowledge about influenza vaccination and the vaccination status of primary care physicians (PCPs) are important factors influencing receivers’ willingness to have influenza vaccines [14‐16]. On the other hand, patients’ mistrust and physical violence towards physicians may affect PCPs’ willingness to recommend vaccine uptakes to the at-risk population in China [17].

In 2009, with the implementation of the national medical reform, China launched the national basic public health service program, which required primary healthcare facilities to deliver defined public health services, including vaccination services, physical check-ups, and health management to older residents. [18]. In urban areas, primary healthcare facilities are primarily community health centres (CHCs). Hence, widely-distributed community health centres are fully responsible for vaccination services to urban residents, including influenza vaccination to older adults [19]. People of all ages can take influenza vaccination at community health centres through making an appointment.

Evidence has shown that providing influenza vaccination free of charge might improve vaccination coverage [20]. To promote influenza vaccination coverage among older adults, some cities in China provide influenza vaccination services free of charge for adults aged 60 and above at CHCs [21]. Since October 2016, Shenzhen, an international tech hub as well as a mega-city in China with more than 0.94 million older adults, started to offer free influenza vaccination services to its residents aged 60 years and above through CHCs. Alongside this free influenza vaccination policy, Shenzhen Centres for Disease Prevention and Control also conducted a community health centre-based experiment. This experiment asked PCPs working in CHCs to proactively offer influenza vaccination recommendations to their older patients in their routine work. Choosing PCPs who work in CHCs to provide vaccination recommendations is because they are responsible for providing health management and follow-up services to older adults under the national basic public health program. Therefore, older patients may be more likely to accept and follow vaccination recommendations during their visits to PCPs in CHCs.

The goal of this study had two folds. First, this study aimed to evaluate whether PCP could improve influenza vaccination among older adults. Second, this study compared the knowledge, attitude, and practice level of influenza vaccination among older adults before and after the free influenza vaccination program implementation in Shenzhen, China. Findings from this study can provide valuable insights regarding health policies on influenza vaccine uptakes among older adults in other regions and contribute efforts to improving influenza vaccination coverage.

Our study provided evidence that PCP recommendation was as an effective intervention in increasing the numbers of influenza vaccine uptake and improving the knowledge, attitude, and practice level regarding influenza vaccination among older adults, with the implementation of free influenza vaccination program. It also highlighted the importance of incorporating PCP vaccination recommendation for older adults in routine work in CHCs.

Our findings were consistent with prior results indicating that healthcare professionals, especially primary care physicians, played an important role in improving influenza coverage among diverse populations [23, 24]. In a previous study, approximately 78% of older adults showed their willingness to take influenza vaccine if being recommended by a physician [15]. However, in a previous situation in Shenzhen, where only community nurses assessed patients’ health status and provided vaccine uptakes directly, PCPs were not directly involved in any step of vaccination services, because recommendations of influenza vaccination were not incorporated in their daily work routines. Hence, patients’ lack of primary suggestions from PCPs on influenza vaccination might be an important barrier in promoting influenza coverage among older adults. Evidence showed that enhancements in professional knowledge in influenza vaccination among PCPs might increase the possibility of vaccination recommendations [25, 26]. The CHCs should provide regular relevant training including delivering knowledge on health education, assessment methods, and recommendations of influenza vaccine uptakes for PCPs. After revising their work routines and obtaining the latest knowledge on vaccines, PCPs know influenza vaccination better objectively and are more likely to follow the instruction of standardised routine to recommend vaccine uptakes to older adults, which acts as the basis of PCP recommendation. PCP recommendation should be included in their daily work routine and CHCs also need to provide opportunities for PCPs to communicate with and deliver this knowledge to their patients.

Although we found that knowledge and attitude regarding influenza vaccine uptakes among older adults were improved after the implementation of free influenza vaccination program, the willingness of patients to take influenza vaccination remained still relatively low [20]. This calls for more policy actions to be conducted in a wider range and more health education efforts should be made in improving the willingness of patients to have influenza vaccine. The free influenza vaccination program might promote influenza vaccine uptake among older adults aged 60 years and above as it is free of charge and incentive for target populations in Shenzhen, China. Since PCP recommendation has been proved effective in improving the numbers of influenza vaccine uptakes, the integration of free vaccination program and PCP recommendation does play an important role in improving knowledge, attitude, and practice regarding influenza vaccination, and increasing the numbers of influenza vaccine uptakes among older adults in the future.

Under the progress of free vaccination program, people started to put more emphases on the influenza prevention intervention measures. In China, PCPs in CHCs were considered as one of the most fundamental healthcare workers to consult with, where people obtained most of their health education related knowledge. According to our results, older patients showed increased willingness to access their vaccination knowledge from PCPs and the internet. Growing interest has shown in the role of internet in public health promotion due to increasing people’s health enquiries on the internet and social media [27]. However, harmful misinformation spreads across networks, including anti-vaccination events, which deepens vaccine hesitancy and misunderstanding [28]. Future intervention could be considered to add more health education about influenza and influenza vaccination in public for older adults not only through PCPs routine, but also websites and social medias. The free influenza vaccination program has been proved effective to improve patients’ willingness to take influenza to some extent, which is consistent with previous research [20]. The effect of integrating influenza vaccination recommendation into the routine work of PCPs combined with free vaccination programs merits verifications in national ranges, but health policies in each region should be developed with features by relevant departments.

Our study has several limitations. First, recall bias might occur in this process as we used a self-reported questionnaire to investigate patients’ knowledge of influenza vaccine uptake. Second, it should be careful when generalizing our results to other cities in China, as Shenzhen is a mega-city, but only 5.36% of its population are older adults [22], which is far below the national average (18.7%) [29]. Third, due to data limitation, some information such as patient characteristics were not available. Further research could be conducted to explore and evaluate more effective interventions to increase influenza vaccination coverage among other at-risk populations.

With the implementation of free influenza vaccination program in Shenzhen, China, PCP recommendation can improve older adults’ influenza vaccine uptake and people’s knowledge, attitude, and practice level towards influenza and influenza vaccination in Shenzhen, China. PCPs should recommend influenza vaccine uptakes to the older populations as their work routine in every health centre in China to improve vaccination coverage. Additionally, the free influenza vaccine uptake programs should be promoted among all older adults in China.