Abstract Introduction Care home (CH) influenza vaccination of staff improves resident health, yet uptake remains low at just over 11% (England, 2025/2026). We report an economic evaluation (EE) of ‘FluCare’, an intervention to increase staff influenza vaccination through: vaccination clinics at CHs; promotional materials; and CH financial incentives. Method Seventy-five CHs were randomised to FluCare or control. A cost-consequence analysis took the influenza vaccination programme funder perspective, but also extended to the National Health Service (NHS) and CH perspective. Costs included: influenza vaccination; administration fee; FluCare components; CH resident NHS utilisation. Outcomes were: staff influenza vaccination rates; staff sickness; and resident mortality. Sensitivity analyses excluded intervention CHs that did not host vaccination clinics. Results Compared to control CHs, adjusted analysis found intervention homes with a mean absolute increase in vaccination rates of 1.8% (95% CI: -6.0%, 10.8%; p=0.572) at an increased cost of £451 (95% CI: £239, £675; p<0.001) to the vaccination programme funders: £249 per additional percentage point (PAPP) per CH. Vaccination clinics were delivered late in the influenza season, with 80% taking place from February 2023. Including only intervention CHs that hosted staff flu vaccination clinics (23/35), increases the mean difference to 10.1% (95% CI: 0.9%, 21.9%; p=0.018) and costs to £805 (95% CI: £603, £1,079; p<0.001): £79 PAPP per CH. Differences between trial arms in other costs and outcomes were marginal and generally non-significant. Conclusions FluCare delivered little improvement when staff flu vaccination clinics did not occur and had little impact on other costs/outcomes. Cost-effectiveness depends on willingness-to-pay for increased staff vaccination, but cost PAPP per CH improved from £249 to £79 when only CHs hosting clinics were considered. Late implementation, likely reduced impact by limiting clinic delivery, as reflected in sensitivity analysis. Future evaluations should implement FluCare earlier in the season. Trial registration ISRCTN22729870. Registered on 24 August 22. Secondary identifiers: R209939, IRAS 316820, CPMS 53812.

Background:To protect care home residents the World Health Organisation recommends that 75 % of care home staff are vaccinated for influenza. In the UK this value is less than 30 %. Previously reported interventions have not been informed by theory and usually only addressed one or two known barriers to uptake. Using behavioural science, we worked with care home staff to develop an intervention which addressed all barriers at both individual and care home level. Methods:We developed an online questionnaire, derived from the literature, asking staff about barriers and facilitators of flu vaccination. These were prioritised (based on frequency and distinctiveness), then mapped to the Theoretical Domains Framework. Relevant behaviour change techniques were identified. Care home staff selected and designed behaviour change techniques according to affordability, practicability, effectiveness, acceptability, safety and equity (APEASE) via an online questionnaire and workshop. Results:The prioritised barriers were: lack of time to get vaccinated; insufficient vaccine supplies; vaccination costs; a lack of peers getting vaccinated and beliefs that staff do not need vaccination and that it is ineffective. Six behaviour change techniques were selected and developed into a multi-component intervention: (behaviour change technique 1, Restructure of the physical environment) Free, in care home vaccination clinics for staff; (behaviour change techniques 2-4, Information about health consequences, Salience of consequences and information about others' approval) information campaign featuring care home staff highlighting non-vaccination risks, (behaviour change techniques 5-6, Information about health consequences and Credible source) information campaign featuring primary care doctor challenging misconceptions. Conclusions:We developed the first theory and evidence-based intervention specifically to facilitate care home staff flu vaccination uptake. Feasibility and acceptability testing of the intervention followed by definitive trial to assess efficacy in care homes is necessary to inform policy decision-making.

Influenza (flu) vaccination rates of Care home staff (CHS) in England are consistently lower (≈ 15

BACKGROUND:Care home staff's (CHS's) influenza vaccination rate in England is 30%-40%, below the 75% WHO recommendation. We describe the effectiveness of a theory-informed and feasibility-tested intervention (in-home clinics; posters/videos to address vaccination hesitancy and care home financial incentives for uptake) to improve CHS vaccination rates. METHOD:Recruited care homes in England with CHS vaccination rates <40% were randomised at the home level for intervention or control. Assuming a change in CHS vaccinated from 55% to 75%, 20% attrition, and 90% power, we required 39 homes per arm. Monthly data were collected throughout flu season. The difference in vaccination rates between the arms was compared using the intention-to-treat principle and a random effect logistic regression model. FINDINGS:The mean % vaccination rate was 28.6% in control (n = 35) and 32.7% in intervention (n = 35) [odds ratio (OR) = 1.29, 95% confidence interval (CI): 0.68-0.4, P = .435]. In a sub-analysis, including only homes receiving at least one clinic, control was 28.6% (n = 35) and intervention was 41.7% (n = 23) (OR = 2.08, 95% CI: 0.67-2.70, P = .045). INTERPRETATION:No effect on vaccination status was demonstrated. Within homes receiving clinics, a significant increase was observed. Process evaluation evidence suggests that starting 3 months into the influenza season partially explains this. Further evaluation initiating FluCare earlier is warranted.

We examine a stylised helping game in which players recurrently decide whether to help others at personal cost and are assigned binary ratings of “helpfulness” based on previous choices. We propose axioms requiring that ratings are responsive to players’ decisions and change monotonically with respect to helping given or withheld. Only four rules satisfy these axioms: two standing rules and two versions of a form of binary image scoring. These results show how a single rating can encode both the “desert” perspective, linking worthiness to kindness and deservingness, and the “club” perspective, relating worthiness to a cooperative club’s membership.

Abstract Background To protect care home residents, annual staff influenza vaccination uptake is recommended to be greater than 75%. In the UK it is under 40%. With barriers and enablers to care home staff flu vaccine uptake identified, the purpose of this study was to feasibility test a theory informed intervention to improve vaccination rates. Methods This was a five-arm (one intervention, four different control) study designed to inform the development of a definitive trial protocol. The intervention comprised of videos/posters to change vaccination attitudes, on-site clinics to increase access, a financial incentive for homes to reach target, and monthly monitoring of vaccination uptake. Control arms consisted of a mix of monthly or end of the study monitoring and provision of informational materials to identify the most suitable control arm for a definitive trial. Care homes were recruited via sector associations and purposively allocated. The feasibility outcomes were: ability to recruit enough homes; data quality (variables reported, variable completeness and consistency with a national reporting system); intervention implementation; control arm reactivity bias and signal of efficacy. Staff vaccination data was collated from homes and via a national healthcare tracking system. Process evaluation and economic data collation were undertaken to optimise intervention and research design. Results Ten homes were recruited as per target within 11 weeks. Recruitment delays meant intervention delivery began towards end of flu season. Only 2 clinics took place in each home. All homes in intervention and chosen control arm (monthly monitoring only) reported all variables with over 90% completeness. There was a 15% difference between control homes’ reported vaccination rates and that in the national healthcare tracker, home reported data was more reliable. Signal of efficacy: intervention arm had a vaccination rate 13.6% higher than control arm. Bias: control arm did not have a higher vaccination rate than usual care control. Conclusions Better recruitment processes, earlier start in flu season, and data collection direct from care homes are required for a definitive trial. A control arm of monthly monitoring only was identified as optimal for data collection purposes and minimising reactivity bias. The signal of efficacy was acceptable. Trial registration ISRCTN 14727552 Registered on 27/08/2021. Secondary identifiers: IRAS 305371

Background/Objectives: Vaccinating care home staff is essential to protect vulnerable residents by reducing infection risks and creating a safer care environment. However, vaccine hesitancy amongst staff remains a challenge, particularly since the COVID-19 pandemic raised concerns about side effects and vaccination mandates. This study examines how the pandemic influenced flu vaccine hesitancy amongst UK care home staff. Methods: Data were collected from the FluCare trials conducted over the 2021–22 and 2022–23 winter seasons to explore the impact of concurrent mandatory and non-mandatory COVID-19 vaccination policies on flu vaccine uptake. A total of 52 interviews (21 from the feasibility study and 31 from the randomised control trial) were conducted with care home managers and staff. Thematic analysis identified key themes shaping staff attitudes toward flu vaccination. Results: Four central themes emerged regarding the impact of the pandemic on staff attitudes and the contextual influences shaping vaccine hesitance: (i) tension between autonomy and morals in vaccination decisions; (ii) the COVID ‘craze’ and the displacement of the flu vaccine; (iii) the role of the COVID ‘craze’ in staff vaccine fatigue; and (iv) conspiracies, (mis)information, and the significance of trust. Psychosocial theories on decision making and health behaviour were used to further interpret the findings. Conclusions: Our findings suggest that post-COVID-19 interventions in care home setting should address the issues of autonomy, vaccine fatigue, and trust to enhance vaccine uptake. Understanding these factors could support more effective strategies to address hesitancy amongst care home staff in future vaccination campaigns.

Background The World Health Organization recommends that >75% of health/social care staff are vaccinated for flu. This target was met for healthcare staff in England during 2020–21; however, despite the COVID pandemic, the Department of Health and Social Care (DHSC) Capacity Tracker only reported 34% of care home staff as vaccinated. Aim Undertake a two arm, open label, cluster randomised controlled trial to assess the effectiveness and cost-effectiveness of FluCare, a behaviour change intervention designed to improve uptake of influenza vaccination by care home staff, compared to usual care, with embedded process evaluation. Setting Community based private, charity, corporate or local authority care homes (residential or nursing) in England. Methods Care homes registered to provide care for older adults, with at least 10 members of staff and a staff flu vaccination rate <40% during 2021/2022 flu season were eligible. Care homes expressing an interest to participate were consented and randomised to the FluCare intervention (comprising of in-home vaccination clinics, a promotional campaign, monthly performance monitoring and care home CQUIN incentive payment if >70% staff vaccinated) or usual care. Care homes identified their preferred GP/pharmacy, who were invited to participate. Care homes maintained a vaccination log which was submitted to the research team monthly. A vaccination log was completed by GPs/Pharmacies after each clinic. Sample Size Based on the assumptions that mean (standard deviation) cluster (care home) size is 54 staff (25), a coefficient of variation of 0.48, control vaccination rate is 55% (assumed higher than the historical rate as COVID has increased interest in vaccination), intervention 75%, intra-cluster correlation coefficient of 0.2 and with 90% power, we require 31 care homes per arm at two tailed 5% level of significance (62 total). Allowing for 20% attrition, 78 homes were required. Results Seventynine care homes were recruited, 75 randomised, 37 to intervention and 38 to control. To date, 27 care homes have been paired with vaccination providers. 28 staff focused flu vaccination clinics have been held and more are planned. Follow-up data collection is ongoing and will end 31st March 2023. Process evaluation is ongoing. Conclusion At the time of abstract submission the trial is ongoing. Findings are due August 2023 and will be presented at the meeting. Funder FluCare is funded by the NIHR Public Health Research (NIHR133455). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Barriers and enablers to vaccination of care home (CH) staff should be identified in order to develop interventions to address them that increase uptake and protect residents. We aimed to synthesis the evidence describing the barriers and enablers that affect the influenza vaccination uptake of care home (CH) staff. METHOD:We searched PubMed, MEDLINE, EMBASE, CINAHL, PsycINFO, AMED, IBSS, SCOPUS to identify quantitative, qualitative or mixed-method studies. Data related to health or social care workers in CHs reported barriers or enablers were extracted and mapped to the Theoretical Domains Framework (TDF); the data within each domain were grouped and categorized into key factors affecting influenza vaccine uptake among CH staff. RESULTS:We screened 4025 studies; 42 studies met our inclusion criteria. Thirty-four (81 %) were surveys. Five theoretical domains were frequently reported as mediators of influenza vaccine uptake: Beliefs about consequences (32 studies), Environmental context and resources (30 studies), Emotions (26 studies), Social influences (25 studies), Knowledge (22 studies). The low acceptance rate of the influenza vaccine among CH staff can be attributed to multiple factors, including insufficient understanding of the vaccine, its efficacy, or misconceptions about the vaccine (knowledge), perceiving the vaccine as ineffective and unsafe (beliefs about consequences), fear of influenza vaccine and its side effects (emotions), and experiencing limited accessibility to the vaccine (environmental context and resources). CONCLUSION:Interventions aimed at increasing influenza vaccine uptake among CH staff should focus on addressing the barriers identified in this review. These interventions should include components such as enhancing knowledge by providing accurate information about vaccine benefits and safety, addressing negative beliefs by challenging misconceptions, managing concerns and fears through open communication, and improving accessibility to the vaccine through convenient on-site options. This review provides a foundation for the development of tailored Interventions to improve influenza vaccine uptake among CH staff.

Purchase - $123.00 Add Paper to My Library Share: Permalink Using these links will ensure access to this page indefinitely Copy URL Copy DOI

The care home staff influenza vaccination rate in England is significantly lower than the 75% World Health Organisation recommendation. This represents a substantial potential for resident harm. Barriers to staff vaccination stem from individual and organisational levels. Existing interventions address some but not all barriers and are not underpinned by behavioural science theory. This study aims to estimate the effectiveness and cost-effectiveness of a theory-informed intervention to improve care home staff vaccination rates compared to routine practice. Set in care homes with both nursing and residential focus, and a range of ownership status, only homes providing long stay care to older people with a staff vaccination rate below 40% are eligible to participate. Participation expressions of interest will be sought using a variety of approaches prior to seeking consent. The primary outcome measure is the proportion of staff vaccinated at 6 months, with secondary outcome measures being proportion vaccinated at 3 months, numbers of staff sick days, general practitioner and nurse visits to care home, care home resident hospitalisations and mortality. Based on the assumptions that the mean cluster (care home) size is 54 staff, a coefficient of variation of 0.48, control vaccination rate is 55%, intervention 75%, intra-cluster correlation coefficient of 0.2 and with 90% power, and 20% attrition, we require 39 care homes per arm. Blocked randomisation will be at the level of care home, stratified by the proportion of non-white care home staff, and implemented by Norwich Clinical Trials Unit. The intervention comprises co-designed information videos and posters, provision of in-house staff vaccination clinics, and incentive scheme and monthly data collection on trial outcomes. Beyond usual practice, the control arm will additionally contribute monthly data. Data will be collected at the start, monthly and at 6 months, and analysis will be blind to allocation. Statistical analysis will use the intention-to-treat principle with the difference in vaccination rates between groups compared using a random effect logistic regression model at the staff-level. This will be the first study to use a theory-informed intervention designed to comprehensively address identified barriers to care home staff influenza vaccination. Trial registration: ISRCTN ISRCTN22729870 . Registered on 24 August 22. Secondary identifiers: R209939, IRAS 316820, CPMS 53812.

When agents’ claims regarding the division of a cake are subjective and conflicting, it is difficult to obtain an outcome that is considered fair by the involved parties. This paper investigates how pre-play communication affects behavior and outcomes in fair division experiments where various procedures are used to obtain an allocation of the available resources. On the one hand, it is known from bargaining experiments that communication often leads to faster agreements and to more egalitarian allocations. On the other hand, communication may facilitate the emergence of minority-exploiting coalitions when procedures are used which are not collusion-proof. We find that communication increases both efficiency and perceived fairness of the implemented division independent of the procedure used to obtain a solution. Interestingly, collusion, while highly beneficial for those participating, is rarely attempted even when private communication channels are available.

How does guilt affect participation in providing public goods? We characterise and analyse completely mixed symmetric equilibria (CMSE) in participation games where players are guilt averse. We find that relative to material preferences, guilt aversion can: facilitate the existence of CMSE; increase or decrease participation; and imply that group size has a non-monotonic effect on participation. Using our equilibrium characterisation we also re-analyse experimental data on participation games and find a low, but positive, guilt sensitivity parameter.

Institutions for co-financing agreements often exist to encourage public good investment. Can such frameworks deliver maximal investment when agents are motivated by reciprocity? We demonstrate that indeed they can, but not how one might expect. If maximal investment is impossible in the absence of the institution and public good returns are high, then an agreement signed by all parties cannot lead to full investment. However, if all parties reject the agreement, then full investment is attainable via a gentlemen's agreement or memorandum of understanding (MOU). Agreement institutions may thus do more than just facilitate the signing of binding agreements; they may play a critical role in igniting informal cooperation underpinned by reciprocity. (C) 2018 Elsevier Inc. All rights reserved.

Can prior voluntary redistribution improve coordination? We theoretically show that distributive preferences, forward induction and signalling all imply that it can. We then experimentally test our predictions by allowing subjects to redistribute part of their endowment before playing a battle of the sexes game. To identify whether the redistribution option increases coordination, and why, we also run experiments with no redistribution and forced redistribution. Our results show that the redistribution option does indeed significantly increase coordination. Disentangling the reasons why, we find that behaviour is most consistent with distributive preferences and one-step of forward induction (rather than signalling or two-steps of forward induction).

Can prior voluntary redistribution improve coordination? We theoretically show that distributive preferences, forward induction and signalling all imply that it can. We then experimentally test our predictions by allowing subjects to redistribute part of their endowment before playing a battle of the sexes game. To identify whether the redistribution option increases coordination, and why, we also run experiments with no redistribution and forced redistribution. Our results show that the redis- tribution option does indeed significantly increase coordination. Disentangling the reasons why, we find that behaviour is most consistent with distributive preferences and one-step of forward induction (rather than signalling or two-steps of forward induction).

Institutions for co-financing agreements often exist to encourage public good investment. Can such frameworks deliver maximal investment when agents are motivated by reciprocity? We demonstrate that indeed they can, but not in the way one might expect. If maximal investment is impossible in the absence of the institution and public good returns are high, then an agreement signed by all parties cannot lead to full investment. However, if all parties reject the co-financing agreement, then an informal deal to invest can lead to full investment. Agreement institutions may thus do more than just facilitate the signing of formal agreements; they may play a critical role in igniting informal cooperation underpinned by reciprocity.

Reciprocity can be a powerful motivation for human behaviour. Scholars have argued that it is relevant in the context of private provision of public goods. We examine whether reciprocity can resolve the associated coordination problem. The interaction of reciprocity with cost-sharing is critical. Neither cost-sharing nor reciprocity in isolation can solve the problem, but together they have that potential. We introduce new network notions of reciprocity relations to better understand this.