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2012 Model Practice Application (Public)

Application Name: 2012 Model Practice Application (Public) : St. Louis County Department of Health : No Flu For You! (An evidence based influenza education campaign)
Applicant Name: Ms. Eleanor Peters, MA, MSPH
Application Title:
No Flu For You! (An evidence based influenza education campaign)
Please enter email addresses you would like your confirmation to be sent to.
Practice Title
No Flu For You! (An evidence based influenza education campaign)
Submitting LHD/Agency/Organization
St. Louis County Department of Health/ St. Louis University
Head of LHD/Agency/Organization
Dolores Gunn, MD
Street Address
111 S. Meramec Ave.
Practice Contact Person
Eleanor Peters

Email Address

Submitting LHD/Agency/Organization Web Address (if applicable)

Provide a brief summary of the practice in this section. This overview will be used to introduce the model or promising practice in the Model Practices Database. Although this section is not judged, the judges use it to get an overall idea about your practice. You must include answers to the following questions in your response:

• Size of population in your health department’s jurisdiction
• Who is your target population/audience, for this practice
• Size of target population/audience, if applicable
• The number or percentage of the target population/audience reached, if applicable
• Describe the nature and gravity of the public health issue addressed
• List the goal’s and objective(s) of the practice and clearly link them to the problem or issue the practice is addressing. Briefly indicate what the practice intends to accomplish overall.
• When (month and year) the practice was implemented.
• Briefly describe how the practice was implemented, what were major activities, and any start-up and in-kind costs and funding services.
• Outcomes of practice (list process milestones and intended/actual outcomes and impacts.
• Were all of the objectives met? 
• What specific factors led to the success of this practice?
• Lessons learned from the practice

Influenza vaccination among non-hospital healthcare workers (HCW) is imperative, but only limited data is available on factors affecting their compliance. The objective of the study was to examine factors influencing hospital and non-hospital HCWs' influenza vaccine compliance and create a subsequent influenza vaccination educational campaign. A vaccine compliance questionnaire was administered to St. Louis HCWs working in all settings in March-June, 2011. Online and/or paper surveys were used to assess compliance with the 2010/2011, 2009/2010, and H1N1 influenza vaccines, and to examine factors that predicted uptake of 2010/2011 seasonal flu vaccine. In all, 3,188 HCWs completed the survey, of which 1,719 (54%) reported spending no work time in a hospital. Compliance rates for all three vaccines was significantly higher (p < .001) among hospital vs non-hospital HCWs. In logistic regression stratified by hospital versus non-hospital setting, and controlling for demographics and past behavior, the determinants of 2010/2011 seasonal influenza vaccination among non-hospital-based HCWs included having a mandatory vaccination policy, perceived importance, no fear of vaccine side effects, free and on-site access, and perceived susceptibility to flu. Determinants of hospital-based HCW vaccine compliance included belief that HCWs should be vaccinated every year, having a mandatory vaccination policy, occupational health encouragement, perceived importance of vaccination, on-site access, and no fear of vaccine side effects. The strongest predictor of compliance was existence of a mandatory vaccination policy. The study concluded that non-hospital-based HCWs' reasons for vaccine uptake are different from hospital-based workers' and as such an educational campaign was warranted. Targeted interventions should be aimed at workers in these settings to increase their vaccine compliance, including implementing a mandatory vaccination policy. Towards that end, the No Flu For You campaign launched on July 29th, 2011. The kick of symposium featured speakers who 'testified' to the effective nature of varying degrees of influenza policies within their organization (no policy/declination statement policy/mandatory vaccination policy). Also on July 29th the NoFluForYou.com website launched as a national resource for those seeking influenza vaccination information, particularly as it applies to non-hospital healthcare workers. NoFluForYou.com contains the following sections, those marked with an asterisk are unique in scope and will be elaborated on further: General Information, *Policy/ Guidance, *Cost Effectiveness/Benefit, *Campaign Library, Professional Education, Links and Literature, and Submit a Success Story.



Overflow: Please finish the response to the question above by using this text area.  Please be mindful of the word limits.

The website also contains video testimonials, a recent news and events section, and a flu vaccine finder widget. The three sections that are particularly unique are Policy/Guidance, Cost Effectiveness/Benefit and the Campaign Library. The Campaign Library section is an out-of-the-box modular "do it yourself" resource for building an influenza vaccination campaign. It contains campaign models, toolkits, timelines and sample questionnaires. It also contains all of the original materials developed for the campaign. All of the non-original materials in this section were pulled from the best and most effective influenza vaccination campaigns nationally and heavily vetted to select the clearest and most useful resources. The Cost Effectiveness/Benefit section is a compilation of the most relevant literature on the subject of the cost effectiveness of influenza vaccination policies for organizations. This section is particularly helpful for an organization investigating implementing a mandatory influenza vaccination policy. The Policy/Guidance section in addition to providing resources of example policies in myriad healthcare organizations, also provides innovative resource support for any organization seeking to implement their own policy in the form of applicable State laws and professional organizational support.
Describe the public health issue that this practice addresses. (350 word limit)


Multiple organizations and agencies, including the Centers for Disease Control and Prevention (CDC), the Advisory Committee on Immunization Practices (ACIP), and the Society for Healthcare Epidemiology of America (SHEA), recommend that healthcare workers (HCW) be vaccinated against influenza each year. Influenza vaccination of HCWs has been shown to not only decrease employee sick leave, but also decrease morbidity and mortality among patients. Conversely, non-vaccinated HCWs have been associated with disease spread in healthcare settings. SHEA has stated that HCW influenza vaccination is an essential patient safety and employee health practice, and that non-compliance should not be tolerated. The CDC has reported that HCW influenza vaccination rates have steadily increased over the last decade, and some healthcare agencies/systems have begun implementing declination and/or mandatory vaccination policies to further increase compliance. Despite this, studies indicate that HCW influenza vaccination rates remain below the Healthy People 2020 objective of reaching 90% coverage.
What process was used to determine the relevancy of the public health issue to the community? (350 word limit)
A literature review was conducted. Studies examining HCW flu vaccination uptake have reported various factors that influence compliance: race, age, gender, having direct patient contact, work setting (hospital versus non-hospital), requiring signed declination forms or having a mandatory vaccination policy, work status (full versus part-time), access to vaccine on-site at work, vaccine provided for free, education related to flu vaccine, perceived vaccine efficacy , leadership support, perceived seriousness of influenza, fear of vaccine side effects, fear of needles, fear of getting the flu from the vaccine, past behavior (i.e., receiving the vaccine in the past), anticipated regret, and professional norm (i.e., perceiving flu vaccine as a professional duty). Although researchers have evaluated a multitude of factors that influence HCW vaccine uptake, most studies have examined hospital-based workers only. Of those studies that examined both hospital and non-hospital HCW immunization compliance, most did not compare hospital versus non-hospital staff, or overall uptake rates were compared, but factors that might influence the difference in rates was not examined. Only one vaccine compliance study focused on a non-hospital setting, and it only examined public health. Influenza transmission can occur in non-hospital settings if HCWs are not vaccinated.
How does the practice address the issue?
This practice addresses the critical factors influencing vaccine uptake among HCWs in non-acute care settings and examined them so that targeted interventions could be developed to increase compliance.
Is the practice new to the field of public health? If so, answer the following questions.

What process was used to determine that the practice is new to the field of public health? Please provide any supporting evidence you may have, e.g. literature review.

How does this practice differ from other approaches used to address the public health issue?
Is the practice a creative use of an existing tool or practice? If so, answer the following questions.

What tool or practice (e.g., APC development tool, The Guide to Community Preventive Services, HP 2020, MAPP, PACE EH, etc.); did you use in a creative way to create your practice?  (if applicable) (300 word limit total)
a. Is it in NACCHO’s Toolbox; (if not, have you uploaded it in the Toolbox)?
b. If you used a tool or practice to implement your practice, how was your approach to implementing the tool unique and innovative for your target area/population?


This practice uses evidence based public health via an online survey to inform an educational campaign for non-hospital based healthcare workers. The innovation of this practice stems from the use of the tool to capture the attitudes and beliefs of the targeted sub field of non hospital based workers in regards to influenza vaccine uptake behavior as opposed to the much researched hospital based workers. Additionally, creating the single stop "how-to" resource of NoFluForYou.com for non-hospital healthcare organizations seeking to implement a stronger influenza vaccination policy is a new advance.
What process was used to determine that the practice is a creative use of an existing tool or practice?  Please provide any supporting evidence you may have, for example, literature review.
A literature review was conducted and nothing similar was found.

How does this practice differ from other approaches used to address the public health issue? 

Influenza vaccination education for healthcare workers has focused almost exclusively on hospital based workers. This myopic consideration ignores the fact that often hospitals have either mandatory programs in place or employer sponsored vaccination clinics where the hospital based employees can get their vaccine at work for free. There are significantly fewer barriers for hospital based healthcare workers to obtain the influenza vaccine than non-hospital based healthcare workers. In this study hospital-based HCWs were significantly more likely (Χ2 = 559.8, p < .001) to report that their employer mandated vaccination (51.3%, n = 752) compared to non-hospital-based HCWs (12.5%, n = 214).
If this practice is similar to an existing model practice in NACCHO’s Model Practices Database (www.naccho.org/topics/modelpractices/database), how does your practice differ? (if, applicable)
Who were the primary stakeholders in the practice?
St. Louis County Department of Health and St. Louis University (and non hospital based healthcare workers)
What is the LHD's role in this practice?
The St. Louis County Department of Health was the funder and Co-Project lead on the campaign.
What is the role of stakeholders/partners in the planning and implementation of the practice?
St. Louis County Department of Health and St. Louis University sought find out what barriers existed for non-hospital healthcare workers in the St. Louis region and created an education based campaign informed by the research. Both organizations were involved with the study design, planning, campaign design and delivery through numerous planning and status meetings and e-mails.

What does the LHD do to foster collaboration with community shareholders?

Describe the relationship(s) and how it furthers the practice's goals.
The local health department maintains regular contact with school nurses, EMTs, home health care workers, nursing home attendants, laboritorians and other non hospital health care practitioners via many methods. Information is often disseminated through another community partner, the Gateway Immunization Coalition's membership e-mail list and the various listserves of the St. Louis County Department of Health.
Describe lessons learned and barriers to developing collaborations
The most significant lesson from this initiative was that multi-sectoral partnering, in this case, Public/Non-Profit/Private, should be utilized wherever possible in public health education. By creating the request for proposal initially, the health department was able to partner with a local university that then used its contacts to reach out to other local partners to create a well designed survey tool, advertising platform for the study and education campaign. This grant within a grant approach allowed for a novel and creative campaign to be born. If the local health department had done the campaign on its own as a result of the primary grant, it would have most likely needed to put the campaign out to bid and would have been compelled to choose the lowest bidder instead of the best solution.

Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improves practice.

Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).

List up to three primary objectives for the practice. For each objective, provide the following information:  (750 word limit per objective)

There were two primary objectives for this practice. The first was to create and implement a survey that would examine factors influencing hospital and non-hospital HCWs' influenza vaccine compliance. The second objective was to create an influenza vaccination education campaign informed by the results of the study.

• Performance measures used to evaluate the practice: List the performance measures used in your evaluation. Depending on the type of evaluation conducted, these might be measures of processes (e.g., number of meetings held, number of partners contacted), program outputs (e.g., number of clients served, number of informational flyers distributed), or program outcomes (e.g., policy change, change in knowledge or attitude, change in a health indicator)
• Data: List secondary and primary data sources used for the evaluation.  Describe what primary data, if any were collected for each performance measure, who collected them, and how.
• Evaluation results: Summarize what the LHD learned from the process and/or outcome evaluation. To what extent did the LHD successfully implement the activities that supported that objective? To what extent was the objective achieved?
• Feedback:  List who received the evaluation results, what lessons were learned, and what modifications, if any, were made to the practice as a result of the data findings.

Objective 1

Creating and implementing a survey that would examine factors influencing hospital and non-hospital HCWs' influenza vaccine compliance: Performance measures: The main performance measure for Objective 1 was the number of respondents to the survey. The target was 2,000 and in all, 3,188 HCWs completed the survey; half of which (n = 1,719) reported no hospital work time. Data: The data collected for this objective was primary data stemming from an internet based questionnaire. Evaluation Results: The findings of the study indicate that many St. Louis region HCWs are getting the influenza vaccine, regardless of whether they work for a hospital or non-hospital setting. Influenza vaccine compliance for the 2010/2011 season was found to be higher in this study than in a national study conducted by the CDC covering the same influenza vaccine period (63.5% compliance per CDC verses 78.9% in this study). Despite the higher vaccination rate found for most HCWs in this study, immunization compliance for St. Louis HCWs still remains well below the target of 90% in Healthy People 2020. HCWs' attitudes and beliefs towards influenza vaccine differed significantly when comparing vaccinated to non-vaccinated HCWs employed in a non-hospital setting. Non-hospital-based vaccinated HCWs were significantly more likely than non-vaccinated workers to agree that influenza is a serious disease (Χ2 = 121.9, p<.001), that HCWs should be vaccinated every year (Χ2 = 621.0, p<.001), that employment should be dependent upon vaccination (Χ2 = 107.8, p<.001), that non-immunized HCWs play a role in influenza transmission (Χ2 = 337.0, p<.001), that vaccination is important to them (Χ2 = 872.0, p<.001), that they would receive the vaccine every year if it was offered free (Χ2 = 738.0, p<.001) or free and on-site (Χ2 = 754.5, p<.001), and that public health can be trusted to produce a safe vaccine (Χ2 = 336.3, p<.001). Non-hospital-based vaccinated HCWs were significantly less likely than non-vaccinated workers to agree that influenza vaccine has a lot of side effects (Χ2 = 194.8, p<.001), that they are afraid of influenza vaccine side effects (Χ2 = 329.5, p<.001), and that they are less susceptible to the influenza because their immune system has become built up from years of working in healthcare (Χ2 = 80.6, p<.001).

Overflow (Objective 1): Please finish the response to the question above by using this text area.  Please be mindful of the word limits.

The study found that few HCWs work for an agency that has a mandatory vaccination policy and having a mandatory vaccination policy was the strongest predictor of HCW vaccine uptake. Along with a mandatory vaccination policy, other interventions can be implemented to increase HCW vaccine compliance: encouraging staff to be vaccinated, decreasing barriers to vaccination, and education campaign implementation. Interestingly, even without a mandatory vaccination policy, encouragement from the employer to be vaccinated made a significant difference in worker vaccination rates. So administrators should be pro-active in encouraging vaccination among their workers. This study found that decreasing cost and access barriers to vaccination was associated with higher uptake rates. Healthcare agencies should provide free vaccine on-site to their staff whenever possible to increase compliance. This is even more critical in non-hospital settings, as cost and access were more significant barriers to vaccination among these HCWs compared to hospital-based workers. Education campaigns can also be an effective intervention in increasing vaccine uptake. Findings from the study indicate that the components of a vaccine education campaign should be targeted to the work setting, with different information provided to non-hospital-based workers compared to that aimed at hospital-based HCWs. Information provided in the education campaign should reflect the HCWs’ attitudes and beliefs as reported in this study. The study found that past behavior was a strong determinant for influenza vaccination. This finding reinforces the need to promote compliance behavior among HCWs who have never been vaccinated, since uptake behavior increases the likelihood that vaccination compliance will continue. Feedback: Since this was a survey, no feedback was collected after the survey was implemented, but there was a pilot survey upfront to ensure that the instrument was complete and reasonable. This pilot (or test/re-test procedure) was completed and the recommendations incorporated into the final survey design. The findings from the survey demonstrate the profound impact mandatory vaccination policies can have on vaccine uptake among HCWs; implementing such a policy should be a priority for all healthcare agencies. The study was used to develop a comprehensive influenza vaccination program and education campaign for hospital and non-hospital healthcare settings.

Objective 2

Creating an influenza vaccination education campaign informed by the results of the study: Performance Measures: The main performance measure for this website is web traffic on the site or utilization rates and figures. Data: The data used here is primary data collected by Google Analytics to measure web traffic to the site. Evaluation Results: In the 3 full months that the website has been live Aug-Sept-Oct 1,012 unique visitors have been to the site with a total of 1,376 visits. In terms of pageviews 4,340 have been recorded. The average time spent on the site being 2.47 minutes. Visitors visited an average of 3.03 pages per visit. The site has been visited from 11 different countries including: the United States, the United Kingdom, Russia, the Philippines, Malaysia, Germany, India, Australia, Canada, China, Israel, Lithuania and one unidentified country/territory. Feedback: So far feedback has been ongoing, solicited and unsolicited. NACCHO and the CDC both promoted the NoFluForYou.com campaign on their websites and in newsletters. Some anecdotal feedback from the general public has been received about a given link on the site being broken or a document being unavailable for download and those issues have been resolved in a timely manner. Since the website is fairly new modifications are ongoing as needed.

Overflow (Objective 2): Please finish the response to the question above by using this text area.  Please be mindful of the word limits.

Objective 3:

Overflow (Objective 3): Please finish the response to the question above by using this text area.  Please be mindful of the word limits.

What are the specific tasks taken that achieve each goal and objective of the practice?
This study consisted of a survey provided to healthcare workers in the St. Louis region in April – June, 2011. The survey was administrated through Qualtrics®, an online program; paper surveys were also made available to subjects or agencies that did not have internet access. Subjects were recruited using two methods: a) two recruitment postcards (sent two weeks apart) were mailed to licensed healthcare workers obtained from the Missouri Division of Professional Registration, and b) two recruitment emails (sent two weeks apart) were distributed to members of healthcare profession organizations and/or agencies who agreed to assist in recruiting subjects. In all, 69 organizations and agencies assisted with subject recruitment (a list of participating organizations/agencies is available upon request). The Saint Louis University Institutional Review Board approved this study. In terms of the instrument, surveys used in earlier studies examining influenza vaccine compliance were used as the basis for this questionnaire. In addition, questions were added that were specific to the purposes of this study. A group of 10 U.S. influenza vaccine researchers provided feedback on the content validity. The content validity index (CVI) was computed for each item ; no items had a CVI below 0.80, so none were deleted. The final survey contained 31 questions plus demographic items. Twenty St. Louis area healthcare workers pilot tested the instrument. The survey assessed the following: a) vaccine uptake of seasonal influenza vaccine during the 2010/2011 season, H1N1 vaccine during the 2009 pandemic, and seasonal influenza vaccine during the 2009 pandemic (2009/2010), b) employer's stance/policy on influenza vaccine, c) HCWs’ barriers to vaccination, d) HCWs’ attitudes and beliefs about flu vaccine, and e) intent to get vaccinated during the upcoming 2011/2012 flu season. Temporal stability of the instrument was assessed using a 2-week test retest procedure among 163 healthcare workers. The questionnaire had good temporal stability, with correlation coefficients varying from .74 to .94.
What was the timeframe for carrying out these tasks?
The survey was administered and promoted March-June 2011. The educational campaign NoFluForYou.com kicked off on July 29th and continues to present.
Is there sufficient stakeholder commitment to sustain the practice?  Describe how this commitment is ensured.
St. Louis County Department of Health and St. Louis University are in the midst of creating a more formal partnership. The partnership is known as The St. Louis Area Public Health Collaborative. This Collaborative is a new venture between the two organizations and a public private partnership that is unique in scope and focus. The St. Louis Area Public Health Collaborative seeks to provide a platform for partnership between the faculty and students in Public Health programs throughout St. Louis University and the St. Louis County Department of Health. The SLAPHC is a council. It is designed to have equal representation from both organizations with multiple members from different departments working together. The St. Louis Area Public Health Collaborative has three primary goals: • To promote and further collaboration between St. Louis County Department of Health and St. Louis University. • To add vital and relevant knowledge to the field of public health. • To advance St. Louis as a premier destination for public health research and practice. The St. Louis Area Public Health Collaborative’s goals will be achieved by fostering three main cooperative objectives: • Sharing technical knowledge and expertise that may include lecturing by St. Louis County staff at St. Louis University, housing visiting staff from one organization at the other and quarterly summits. • Jointly supervised practicum/internship experience for all levels of students (Undergraduate, Graduate, Post graduate, Fellows) from St. Louis University at the St. Louis County Department of Health • Joint research endeavors that include but are not limited to, proactively seeking joint funding opportunities, completing grant applications authorship of scientific papers, and conducting studies. St. Louis Area Public Health Collaborative (SLAPHC) activities will be carried out with effort and support from both entities. The products and data stemming from the collaborative will be jointly owned by the St. Louis County Department of Health and St. Louis University.
Describe plans to sustain the practice over time and leverage resources.
The St. Louis County Department of Health has taken responsibility of the nofluforyou.com domain and website and will maintain and promote it. There are also active partnerships between the health department and area non profits, such as the Gateway Immunization Coalition, that will be leveraged to continue to advertise and promote the campaign.
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