To the Editor—The Veterans Health Administration strongly encourages all employees to receive an annual influenza vaccine, with the goal of achieving a 90% vaccination rate among healthcare personnel (HCP) by 2020.¹ A nationwide survey conducted by Schult et al. queried reasons that Veterans Affairs employees did not get the 2009–2010 influenza vaccine, offering 12 specific reasons for declining the vaccine.Reference Schult, Awosika and Hodgson² Interactions with employees at two Veterans Affairs Medical Centers (VAMCs) raised the possibility of a wider array of reasons for vaccine refusal. We surveyed employees at both VAMCs regarding their reasons for accepting or declining the influenza vaccine in the 2013–2014 season, including the option to explain their views using comments entered as free text.

The institutional review boards at both participating facilities reviewed and approved the survey and study design. Employees at two VAMCs were invited via e-mail to participate in an anonymous, voluntary survey, accessed through an Internet link, that took <5 minutes to complete (Qualtrics, Provo, UT). The survey included questions similar to those previously described with the addition of free-text options for respondents to further explain their views.Reference Schult, Awosika and Hodgson^{2, 3} Each of the authors independently reviewed the free-text responses and grouped them into themes. Some respondents offered comments that fit >1 theme.

Of 498 respondents, 477 (96%) completed the survey. Among these, 363 (76%) reported receiving the 2013–2014 influenza vaccine. Respondents indicated the following reasons for getting a seasonal influenza vaccine: protect self (91%), protect friends and family (82%), availability of vaccine without cost (65%), protect patients (57%), previously had “the flu” (27%), healthcare provider recommendation (21%), mandatory requirement at a non-VHA workplace (8%), and other (6%). Respondents indicated the following reasons for not getting an influenza vaccine: other (53%), concern about side effects (37%), gives me “the flu” (17%), not needed (11%), does not work (11%), allergy (9%), dislike of shots (8%), healthcare provider recommendation (6%), sick when the vaccine was offered (4%), forgot (4%), no time (4%), attempted but not able (1%), and did not know I needed it (0%).

Among those who indicated that they received the vaccination, 95 individuals (26%) offered a total of 105 comments in the free-text portions of the survey. Among these, 31 respondents had suggestions for improving access or acceptance of the vaccine, 17 reported that convenience was part of the reason they took the vaccine, and 13 indicated that they take the vaccine every year. Four reported that they still became ill with influenza.

Among those who did not receive the vaccine, 65 individuals (57%) made a total of 82 comments in the free-text portions of the survey. Despite having 12 familiar rationales to choose from, most non-vaccinated respondents included “other” as a reason for refusing vaccination. While many of the comments expanded on the 12 rationales offered, 41 comments (50%) offered reasons not already included in the survey. We examined the themes of these comments, finding that 18 respondents cited alternative protection strategies for influenza prevention, while 13 offered a quasi-scientific rationale, 10 expressed mistrust of the government and pharmaceutical industry, and 9 indicated concern related to vaccine components (Table 1).

TABLE 1 Examples of Comments from Respondents Who Reported Not Getting the Influenza Vaccine

^a Some comments have been edited for length or clarity.

Although the results from the multiple-choice portion of our survey were similar to those reported previously, analysis of free-text comments revealed rationales that had not been included on similar surveys.Reference Schult, Awosika and Hodgson^{2, 3} Addressing these rationales may suggest strategies for improving influenza vaccination rates among HCP. The Centers for Disease Control found that influenza vaccination rates among HCP are highest in settings where the vaccination is required.Reference Black, Yue and Ball⁴ Absent a mandatory requirement, targeted education remains the principal strategy for increasing influenza vaccination rates. Concerns raised by our survey respondents suggest additional themes to incorporate into educational campaigns. To allay concerns about ingredients or chemicals, highlighting the use of thimerosol-free vaccine may increase acceptance. Additional information about the economic benefits of influenza vaccination, extending to reducing healthcare costs, may create a positive interpretation of possible financial motivations. Details about the potential for someone with mild symptoms to transmit influenza to less fortunate people who lack a robust immune system might appeal to individuals who believe their personal immune system can withstand an influenza infection. This reasoning could be supported by a theme of altruism, asserting that HCP have an ethical and moral responsibility to protect their patients from influenza. Finally, frank acknowledgment that the influenza vaccine is not always effective may increase trust toward the campaign as a whole. This message should be closely coupled with an explanation that the protection conferred from this year’s vaccine may help offer personal immunity toward future influenza strains as well as decrease mortality among patients.Reference Voordouw, Sturkenboom and Dieleman^5–Reference Nichol, Nordin, Nelson, Mullooly and Hak⁷

Our study has some limitations. Based on the approximate numbers of total employees, we estimate low response rates: 14% at Facility A and 5% at Facility B. Additionally, the survey was sent to all employees at the medical centers rather than only those with direct patient contact. Furthermore, VAMC employees who refused the vaccine due to strong internal beliefs (ie, concerns about government/pharmaceutical industry) may have been more likely to participate in our survey, compared to those with less emotionally charged reasons (ie, forgot or sick when offered), creating a bias toward those with grievances about the vaccine. Nonetheless, given that 50% of our respondents chose “other” as a reason for declination, we recommend that future survey designs include candid comments from HCP.