A digital communication strategy to increase uptake of the annual influenza vaccination in a healthcare workforce
About the author
Martin Flegg Chart.PR FCIPR is a PR professional specialising in internal communication. He is also a guest tutor and assessor for PR Academy on CIPR qualification courses.
This document was prepared by Edwards Sills for a CIPR Digital Communications Diploma assignment and has been edited for publication by Martin Flegg.
This case study explores the issue of increasing the take up of the annual influenza (flu) vaccination amongst Healthcare Workers (HCWs), with a specific focus on the organisation DHU Health Care.
DHU Health Care, is a provider of healthcare services for the NHS, and is positioned below the national average for its HCWs having the annual flu vaccination.
This case study exposes barriers to vaccination uptake amongst HCWs to explore how a digital communications strategy could use a behavioural change approach to target identified stakeholder groups to increase the take up of vaccines.
Note: In the UK, the annual seasonal flu vaccination campaign runs from September to March.
DHU Health Care is a National Health Service (NHS) provider supplying NHS 111 and Out-of-Hours Urgent Care services to millions of patients in a region of the UK. Each year the NHS encourages colleagues, including those working for DHU, to protect themselves, their families and their patients by taking up the offer of a free flu vaccination.
The flu has a serious impact on the health of thousands of people every winter, and with the added risk of COVID-19, vaccination is one important way of ensuring DHU’s staff remain healthy and do not infect patients. Historically (2020-2021), the target for flu vaccination has been 80% of the workforce, but in some parts of the organisation this has not been achieved, and it is expected that the vaccination target will increase in subsequent years.
As part of the seasonal flu campaign, all DHU workers are offered a free flu vaccination. Around 75% come forward for it – but that still leaves a quarter of the workforce to engage with, to encourage take-up.
Each year the Flu Planning Team at DHU, led by an Infection, Prevention and Control (IPC) Team, plan and implement the annual campaign with the involvement of key internal stakeholders. In previous years the communications element of the plan has focused on the use of traditional channels such as notice boards, giant thermometers, posters, promotional materials (branded pens, mugs etc) and email. Whilst the traditional methods of communicating the message to colleagues had some success, an updated strategy will use a ‘digital first’ approach in its execution.
As a 24/7 workforce operating across 30 locations, a digital communications strategy has the potential to reach stakeholders that traditional methods of communication may have failed to do, and help drive increased vaccine uptake.
Overview of research methodology
The research methodology used both quantitative and qualitative methods within the situational analysis primarily using internal and external secondary data from the previous two years of flu vaccination campaigns in DHU and the NHS in the UK. Additional data was also reviewed from wider sources such as academic journals and from government policy.
All data accessed for the research was publicly available and internal quantitative feedback was anonymised.
The research and strategic communications approach was informed by the COM-B and EAST models created by the Behavioural Insights Team (BIT), which was originally established to develop public services policy within UK Government.
Behavioural insights have been used successfully within public health and the healthcare sector to change behaviour. So, a rationale for using this approach to inform a future DHU flu vaccination strategy was relevant, and had the potential to produce better health outcomes at a lower cost.
To change behaviours, barriers to vaccine uptake needed to be identified and a digital communication strategy built around helping the identified stakeholders to overcome them. The primary stakeholders for the strategy were identified as being internal colleagues, however external stakeholders could also be influential and were also analysed.
The BIT COM-B model, includes three conditions which a target audience have to meet before a behaviour can take place. These are:
The situational analysis explored the barriers to meeting these conditions, so that relevant objectives could be defined and digital communication interventions developed to change behaviours.
The strategy was also informed by a second BIT framework ‘EAST’, which defines four considerations when developing communication interventions.
In order to obtain insights into vaccination uptake amongst key stakeholder groups, the following data sources and tools were used.
Internal data sources
Internal data from the DHU Human Resources and Business Intelligence Team relating to flu vaccination uptake was analysed. Staff eligible for a flu vaccination were defined as being those in full time employment at the start of the annual campaign in September.
To understand how effective the previous flu vaccination campaigns had been within the organisation the research looked at the data concerning uptake, and also communications content and how this was delivered to the workforce.
Historical research had also been conducted to assess flu vaccination uptake and hesitancy amongst colleagues. Data from a DHU 2018 post-vaccination campaign questionnaire was available which related to uptake, awareness and reasons why colleagues chose not to have the vaccine. Though a small data set, which had not been repeated in subsequent year’s campaigns, it was relevant and was therefore used in both a quantitative and qualitative capacity.
External data sources
From a wider NHS perspective, the research used Public Health England (PHE) data taken from its weekly and annual surveillance reports published on the UK.gov government website.
The annual data of the percentage of NHS frontline HCWs who had accepted the flu vaccination and trend reporting across the NHS network, was particularly relevant as a comparative for DHU vaccine take up.
Relevant information from online journals (BCM Nursing, BJM), healthcare publications (such as the Nursing Times) and Local Government initiatives were also reviewed and analysed.
Social listening tools and free data aggregators such SocialSearcher.com and Answerthepublic.com were used to pull out key trends relating to flu vaccination. Specifically, keywords and phrases relating to flu vaccination amongst HCWs were searched against relevant terms, such as ‘decline, refusal, myths, hesitancy etc.’ to source data and profile people outside the organisation.
Key findings from the analysis and conclusions
Using secondary research to cross reference DHU Health Care’s internal data against the wider NHS government data, and specifically that of a comparative local NHS provider, it was possible to define the scale of the current issue facing the organisation, relating to vaccine uptake.
This part of the research revealed that DHU Health Care, although smaller than the local provider in employee numbers, had improved vaccine uptake, but was still 10% below the national average for vaccinated staff. Nationally, healthcare providers’ vaccination levels ranged sharply from lows of 60% to highs of 100% and in parallel to this, individual service areas within DHU varied substantially, with the NHS 111 service performing best at 95% (2020-2021).
It was also noted that in 2020, due to the Covid-19 pandemic, infection, prevention and control measures were higher and subsequently flu transmission and cases amongst the population were much lower than previous seasons. In response to the pandemic, overall flu vaccination levels amongst HCWs were somewhat higher than usual with PHE data revealing that 76.8% of HCWs had accepted the vaccine, the highest ever uptake ever achieved.
Conclusion: To match the NHS flu vaccination average for HCW, DHU should aim to increase uptake by 11%.
A stakeholder analysis using Mendelow’s stakeholder matrix, exposed DHU as being a part of multi-stakeholder group. Those stakeholder groups with the highest power/highest interest were noted as being, all of DHU’s workforce, the NHS Service Commissioners and patients. These groups would need to be managed closely throughout the campaign.
Conclusion: DHU health care staff, relevant CCGs and patients would be key audiences to help increase flu vaccine uptake.
The analysis of DHU’s internal data demonstrated that flu vaccination uptake rose most sharply at the launch of the campaign. This was likely to be due to awareness of the campaign being at its highest at this point, and HCWs taking action to prepare for the winter period.
In the 2020-21 vaccination programme, early adopters were quick to get their vaccination with a majority of staff following suit throughout December. The flatlining of vaccine uptake towards the beginning of the subsequent calendar year in both campaigns was also evident. This implied poor late adoption for which the causes needed to be better understood and addressed. This trend was also seen to occur across the wider NHS.
Conclusion: Execute communication interventions post-December to reinforce the earlier messaging around vaccine uptake.
In 2018 an internal survey was issued to the DHU workforce to obtain data on the performance of the previous year’s flu campaign. 140 DHU colleagues completed the survey. Whilst 90% of respondents said they definitely/probably would get the vaccine in the forthcoming year, many made suggestions on improvements which could be made which were pertinent to understanding the focus of a subsequent strategic digital communications approach.
When asked “What would improve the probability of getting the Flu Vaccine?” the overall responses focused on education, awareness (overall ease of availability, regular clinics etc.) and incentives.
Conclusion: Improve access and awareness of vaccination clinics and vaccinators and consider incentivisation.
The 2018 survey also asked about the reasons for declining the flu vaccination. It was noted that these findings should be treated with caution as the sample was small with only 36 out of 140 responding. Responses to this question showed that the primary reason for not being vaccinated was an inability to access the service. The secondary areas of concern related to becoming ill with side effects following vaccination and ethical, religious and moral objections.
Similar trends were also identified amongst the wider public via social listening. Using keywords in the analytical tools ‘Answer the Public’ and ‘SocialSearcher’, similar issues were observed relating to whether or not flu vaccination was necessary/worth it, efficacy levels, suitability of the vaccine for halal/vegan patients and safety concerns for those who were pregnant.
Wider studies by Ford, Shrikrishna et al, and Pless et al also revealed that despite the benefits to patients related to protecting them from infection, uptake of flu vaccinations amongst HCWs were often low. All of these three research studies highlighted reasons for HCWs declining the offer of a vaccine. These included assertions that they were healthy with a strong immune system (therefore flu vaccination was not required), they had previously experienced side effects and overarching issues related to trust in authority and access/convenience. These barriers were congruent with the findings from the internal DHU research and validated them as issues which would need to be addressed by messaging in any communications campaign.
Conclusion: Produce a fact based, bold campaign to address prevalent barriers to vaccine uptake.
Application of COM-B and EAST
Having identified some of the key barriers around vaccination uptake on both a national and organisational level, a COM-B diagnosis was then used to categorise the drivers into three groups.
The COM-B model is a way of analysing behaviour by looking at the three processes of ‘Capability,’ ‘Opportunity’ and ‘Motivation.’ It is the interaction between the three processes that is said to cause a change in behaviour.
COM-B was selected as a valuable way of thinking about the causes and barriers behind the issue of flu vaccination, particularly when looking at the individual components of the model such as physical, psychological, reflective and automatic.
For example, it was recognised that education alone would not be enough to persuade HCWs to have the vaccine; especially given a large majority of HCW already knowing the risks of catching the flu, and that a combination of interventions would be required to overcome the barriers and drivers.
The targeting of these drivers would support a strategy of behaviour change and address the challenge of vaccination uptake within the organisation.
The EAST framework was then used to consider how the digital communication activities could be implemented, in the context of the drivers.
Easy: Use digital channels to remove obstacles to accessing flu vaccination information for the staff.
Attractive: Listen to reasons for colleagues not having the vaccination (side effects, trust, good health) and reward those who have had their vaccine (attract attention and provide incentives). Use social networks to share and influence and make accepting the vaccine attractive.
Social: Promote bold, simple key messaging across digital channels around protecting and caring for yourself and others. Partner with stakeholders to increase take-up (normalise and network).
Timely: Use infographics across digital channels, keep staff aware of how well they are doing. Show number of days lost in absence due to flu. Prompt staff around September (start) and January (mid-point flatline) with these communications to make them timely.
The three elements of Tilley’s Ethical Pyramid – intent, means and ends – were used to inform the ‘ethical reasoning’ within both the research methodology and the development of the strategic communications approach and supporting tactics. This ensured compliance with governance/privacy rules and that ethical communications practice was applied throughout in the use of organisational/personal data relating to employees, in the sharing of medical/patient information, evaluation, and the implementation of persuasive communication approaches designed to influence behaviours.
Aims, objectives, activities and evaluation
Using the conclusions from the research, the overarching aims of the digital communication strategy were determined to be a 75% per cent uptake of the flu vaccine within DHU and to promote vaccine uptake amongst wider stakeholders.
Objectives and supporting activities
Objective 1 – Increase the convenience of being vaccinated for internal stakeholders.
The research highlighted problems around access and convenience in obtaining a vaccination. As DHU is a 24/7 365 company operating from many locations more flexibility was required to access the vaccine, remove barriers and influence increased take-up.
- Create a dedicated and branded ‘Flu campaign’ intranet page as a digital information ‘hub’, including a digital form to request a vaccine and relevant supporting information, and encourage staff to visit this.
- Schedule reminders, via internal digital channels, to nudge staff towards the intranet page and digital booking form.
Objective 2 – Conduct a mid-Winter communications campaign to reinforce messaging around vaccine uptake and maintain momentum.
The research highlighted flatlining of vaccine uptake at the start of the calendar year in both of the previous year’s campaigns. Communicating reminders at this time should improve momentum in vaccine uptake.
- Repeat key messaging across all digital channels.
- Focus on motivating staff to get their vaccination for Christmas, with the messaging around protecting family over the festive period.
Objective 3 – Frame the annual flu vaccination as being a social norm for identified key stakeholders.
Normalising vaccination by demonstrating in communications that a majority of people perform this desired behaviour should nudge internal stakeholders into accepting the vaccine for the benefit of both themselves and the wider community. By publicly committing to the annual flu vaccine, stakeholders both promote and exert peer pressure upon late adopters.
- Use digital channels to emphasise rewards for staff, for example a donation will be made to a chosen charity for every vaccination given and share what the charity is doing with donations. This tied in with an overarching theme of ‘helping yourself and others.’
- Create and distribute a digital “I’ve been vaccinated” ‘flu shield’ sticker for vaccinated staff to add to their email footer/social media accounts.
Objective 4 – Challenge misinformation and flu vaccine hesitancy issues.
Both the internal and external research highlighted key trends around vaccine hesitancy and refusal, including worries about side effects, organisational trust and perceived natural immunity. Target both internal and external stakeholders to increase understanding by repeating positive facts, as opposed to busting myths which can inadvertently reinforce them.
- Content should be simple, bold, factual and repetitive in messaging. Ensure that messaging is accessible and representative of all levels of the organisation.
- Link to organisational values to create messaging around ‘protecting your patients, family and loved ones.’
- Acknowledge and address hesitancy reasons, and focus on benefits, in messaging.
Evaluation of the four objectives would be undertaken using monthly intranet analytics of page visitors, social media analytics, post campaign survey data and vaccine uptake figures during and after the campaign.
Despite the research being completed at a late stage in the planning for the 2021/22 flu campaign, DHU took action to implement some of the recommendations. In particular, adapting the messaging in external social media and internal communications content to align with the EAST framework recommendations in the proposal.
The messaging and information were presented in a big, bold and clear format, containing bite sized information. This focused on the barriers identified in the research in Q&A style posts. For example, ‘I am healthy, do I really need a flu jab?’
The messaging approach was factual, and any myth busting tactics were avoided to prevent any reinforcement of myths, and inadvertently creating misinformation. A potential consequence of a myth busting communications approach.
An intranet page was also created as a ‘digital hub’ and a core repository of all the key information relating to getting vaccinated, including details about the flu vaccinators, who they were and where they could be reached to obtain a flu vaccine. The existence of the hub created an opportunity in the rest of the campaign communications to signpost and link employees to this up-to-date digital information resource.
A similar flatlining of vaccination rates was observed mid campaign to that highlighted in the research. As a response, and informed by the recommendations, DHU issued further communications before the Christmas break as an attempt to maintain momentum. The messaging focused on taking responsibility by getting a vaccination to protect yourself, family, friends and work colleagues in time for Christmas. More reminder communications were then issued post-Christmas containing adapted reminder messaging that the flu season was still ongoing, that it was not too late to obtain a vaccine and that the protection this offered against infection could still be beneficial.
Incentivisation was also used in the campaign as an opportunity to increase vaccinations, responding to employee suggestions in the research that this would encourage colleagues to get vaccinated. A donation was made to a local charity supporting a hospice, for every vaccination given.
Throughout the campaign, competing Covid 19 messaging and ‘vaccine fatigue’ amongst employees and in wider society presented a challenge in getting the information about flu vaccination noticed by target stakeholder groups. DHU will be looking ahead to the 2022/23 flu season with an intent to more fully use the recommendations made following the research.
Edward Sills – What I learnt from completing my digital diploma assignment
“Doing the digital diploma course has made me think in a more strategic way about the communications work I do, especially how I plan out campaigns to make them more proactive, rather than reactive, to increase their impact.
Anyone who works in a communication role will know that no two days are ever the same and it’s incredibly busy all of the time, especially working in a healthcare role like mine. Against that backdrop, planning and developing a strategy might feel like just another thing to do and time not well spent. However, the end result of having a clear strategy in place is that you do in fact save time because the communications end up being more impactful and effective. So, there is real value in strategic communications planning.
Understanding more about communication theory and models, such as COM B and EAST, has been a new way of looking at things for me. These models of behaviour change have really made me re-evaluate how I create communications and put them together, particularly in respect of messaging. Even small changes in messaging can make a huge difference in how well communications are received, how people engage with them and ultimately influence their behaviour in a positive way.
Another big takeaway from the course, has been gaining a better understanding of why you should measure communication. It’s really not a case of just doing it, and then seeing if it has worked anecdotally. It’s all about having a baseline, then applying behavioural change theory or whatever model you are using in developing the communications. Then, seeing how the results of the campaign have impacted on the original baseline measure. This is the only way to really measure the success of communication and to inform any adjustments to future communications activity to build on that.
It was also great to create connections and build a community with the other students on the course. This was so important for study support and is something we have continued now the course has finished. Building enduring connections with other people working elsewhere in the communications and PR industry isn’t necessarily something you would expect out of doing a course like this, but it has definitely been one of the highlights”
COM-B and EAST models – Government Communications Service. 2018. Strategic Communications: a behavioural approach.URL: https://gcs.civilservice.gov.uk/publications/strategic-communications-a-behavioural-approach/
Mendelow, A. L. 1991. Environmental scanning: The impact of the stakeholder concept. In Proceedings from the second international conference on information systems. Cambridge, MA.
Ford, M. 2020. Nursing Times survey reveals views on flu and Covid-19 vaccines. Nursing Times. URL: https://www.nursingtimes.net/
Shrikrishna D, Williams S, Restrick L, et al 2015. Influenza vaccination for NHS staff: attitudes and uptake BMJ Open Respiratory Research. 2015;2:e000079. doi: 10.1136/bmjresp-2015-000079
Pless, A., McLennan, S.R., Nicca, D. et al. 2017. Reasons why nurses decline influenza vaccination: a qualitative study. BMC Nurs 16, 20 URL: https://doi.org/10.1186/s12912-017-0215-5
Tilley, E., 2005. pp305-320. The ethics pyramid: Making ethics unavoidable in the public relations process. Journal of Mass Media Ethics. 20(4).