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Flu vaccination uptake amongst healthcare workers in England is below the NHS target of 75%. Reasons may include mixed views on the vaccine’s effectiveness, side effects and belief they are unlikely to catch or transmit flu.

Surprisingly, practical barriers such as time and access to vaccination were not mentioned in this systematic review of qualitative studies for the Department of Health. Though it included mainly North American studies, the findings are consistent with issues raised in the UK about organisational barriers and individual beliefs.

Vaccination campaigns may usefully incorporate peer-to-peer influence, for example through local champions, as well as commitments by leaders and managers. Top-down policies by managers to increase vaccine uptake among staff could be perceived as necessary but potentially disempowering.

Why was this study needed?

Flu is a highly contagious respiratory virus which can lead to serious complications. The infection results in around 8,000 deaths per year in the UK. Healthcare workers can pass on flu, even if they do not have symptoms, to patients in clinical risk groups. Vaccinating practitioners can be cost saving when staff sickness absence is taken into account.

Annual flu vaccination is voluntary and free for NHS staff and delivered through employers. NHS providers receive a CQUIN payment according to the proportion of staff vaccinated. Despite tailored educational materials, a clinical evidence briefing and an NHS Flu Fighter campaign, only 64% of frontline healthcare workers had been vaccinated by the end of 2017 for the 2017/18 flu season.

Policymakers would like to understand the reasons for this relatively low uptake. This review aimed to synthesise research findings on healthcare practitioners’ beliefs and experiences about flu vaccination.

What did this study do?

This systematic review drew on 25 small-scale qualitative studies published between 2002 and 2016. Most studies were carried out in North America, with a few in Australia and Europe but none in the UK. In 16 studies, researchers spoke to healthcare workers in hospitals, primary care and long-term care. The remaining studies collected data from managers, occupational health staff and other stakeholders.

The reviewers synthesised the findings of individual studies into high-level themes. To find studies, health-focused databases and organisational websites were searched. This may have missed research in psychology and social sciences.

Studies were of variable methodological quality and depth. Healthcare settings, characteristics of practitioners and vaccination uptake interventions may vary from the UK.

What did it find?

  • Many practitioners believed that flu vaccination could potentially protect themselves, their vulnerable patients and their families. Study authors suggested that self-protection was the predominant motivator. Yet workers in a range of studies thought it unlikely that they would get flu because of their younger age, good health and strong immunity.
  • Some practitioners spoke of limited vaccine effectiveness due to viral mutation and different strains. They mentioned side-effects such as flu-like symptoms. There was a perception that hand washing and staying away from work when unwell are effective alternatives. Beliefs were based on an assessment of clinical research evidence, and knowledge from peers, the media and alternative health sources.
  • Both practitioners and other stakeholders discussed that relationships between management and employees, and relationships between colleagues, created a social and organisational context for vaccination decisions.
  • Healthcare workers wanted evidence-based information addressing their specific concerns about vaccination. They discussed feasibility and ethics about mandatory policies or a requirement to state their reasons for declining vaccination. Practitioners had experienced compulsory vaccination in only one study.

What does current guidance say on this issue?

Public Health England’s Green Book (updated 2017) recommends that healthcare and social care workers in direct contact with patients and clients should be vaccinated against flu. They recommend either an inactivated vaccine delivered via intramuscular injection or a live attenuated vaccine delivered via a nasal spray. The vaccination should take place in autumn before the “influenza season”. This protects against two strains of influenza A and one of influenza B.

NICE is developing a guideline on increasing flu vaccination uptake, but there is no expected publication date yet.

What are the implications?

Public Health England’s clinical evidence briefing for healthcare workers on flu vaccination already addresses the beliefs highlighted in this review. Interventions based on the influence of colleagues include peer education, flu vaccination champions among staff, and peer vaccination.

Actions to address the practicalities of staff vaccination are also prominent in NHS campaign materials, for example, reminders and extended-hours clinics.

Research needs to look at the feasibility of a mandatory approach for staff in different UK health and social care settings. There have been recent debates on compulsory vaccination in the British Medical Journal. It is to be introduced in Finland from March 2018.

Citation and Funding

Lorenc T, Marshall D, Wright K, et al. Seasonal influenza vaccination of healthcare workers: systematic review of qualitative evidence. BMC Health Serv Res. 2017;17(1):732.

This project was funded by the Department of Health’s Policy Research Programme.



NHS Choices. Flu. London: Department of Health; updated 2017.

NHS website. Who should have the flu jab? London: Department of Health and Social Care; updated 2018.

NICE. Flu vaccination: Increasing uptake (draft guideline). PHG96. London: National Institute for Health and Care Excellence; 2017.

PHE. Chapter 19, Influenza: The Green Book (Immunisation against infectious disease).  London: Public Health England; 2013, updated 2017.

PHE. Healthcare worker vaccination: clinical evidence (updated August 2016). London: Public Health England; 2016.

Shrikrishna D, Williams S, Restrick L, et al. Influenza vaccination for NHS staff: attitudes and uptake. BMJ Open Resp Res. 2015;2(1):e000079.

Sahib B. Not to be sniffed at: flu vaccination for NHS staff. London: King’s Fund blog; 2018.

Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre


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Flu vaccination of eligible adults by injection is recommended annually, using an inactivated form of the virus. Each year, the vaccine takes account of the predominant viral strains circulating that season. Vaccine effectiveness varies from year to year. In 2016-17, the vaccine reduced the risk of flu by around 40% for working-age adults.Qualitative research uses interviews, focus groups, documents or observations to explore the range of participants’ perceptions, experiences and behaviours. Findings are presented narratively rather than using statistics. Samples are typically much smaller than in quantitative research. 
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