Influenza vaccination, inverse care and homelessness: cross-sectional survey of eligibility and uptake during the 2011/12 season in London

Abstract

BackgroundInfluenza vaccination eligibility and uptake among homeless adults has not been previously assessed in the UK. This cross-sectional survey aimed to measure the proportion of homeless people visited by an NHS outreach service (Find and Treat) who were eligible for and had received vaccination during 2011/12.MethodsA cross-sectional survey was carried out in 27 separate homeless hostels, day centres and drug services in London between July and August in 2012. Eligibility for the survey was by virtue of being in attendance at one of 27 venues visited by Find and Treat. No specific exclusion criteria were used.Results455 clients took part in the survey out of 592 approached (76.9%). A total of 190 homeless people (41.8%; 95% CI: 34.5,50.5) were eligible for influenza vaccination. In those aged 16–64, eligibility due to clinical risk factors was 38.9% (95% CI: 31.5,48.2). Uptake of vaccination in homeless 16–64 year olds with a clinical risk factor during the 2011/12 influenza season was 23.7% (95% CI: 19.8,28.3) compared to national levels of 53.2% (excluding pregnant women). In those aged over 65, uptake was 42.9% (95% CI: 16.7,100.0) compared with 74.0% nationally.ConclusionsThis study demonstrates that the homeless population have high levels of chronic health problems predisposing them to severe complications of influenza, but vaccine uptake levels that are less than half those seen among eligible GP patient groups in England. It provides a clear example of the health inequalities and inverse care law that impact this population. The results of this study provide strong justification for intensifying efforts to ensure homeless people have access to influenza vaccination.

Factors influencing the uptake of influenza vaccine vary among different groups in the hard‐to‐reach population

“…However, a UK study has shown that influenza vaccine coverage of homeless people with other risk factors for severe influenza was 23.7% in those aged 16–64 years, and 42.9% in those aged 65 years and older. This is lower than the UK national coverage in the corresponding age group with risk factors for severe influenza (53.2% in those aged 16–64 years, and 74% in those aged 65 years and older) 6 …”

“…Among these, 42% reported not being worried about getting influenza as the main reason for not having the vaccine. Homelessness has been associated with low influenza vaccine uptake in a number of studies 6,20 . It is also likely that participants attending a crisis centre are likely to be worried about more pressing needs such as food, water and shelter, with preventive health measures less of a concern 21 .…”

“…They include people aged >65 years; children aged <5 years; Aboriginal and Torres Strait Islander Peoples; people with Down syndrome; pregnant women; homeless people; smokers; and those with chronic diseases and other health conditions such as cardiac disease, obesity, chronic respiratory conditions, chronic neurological conditions, immunocompromised conditions, chronic liver disease and diabetes mellitus 2,3 . While there is no unified definition of ‘hard‐to‐reach’ populations, studies exploring influenza vaccine coverage for this group have generally included ethnic minorities, immigrants and homeless people 4–6 . For the purpose of this study, we have defined ‘hard‐to‐reach’ population as those who do not access healthcare services due to a number of factors, such as being from an ethnic minority, homeless or in financial crisis.…”

“…2,3 While there is no unified definition of 'hardto-reach' populations, studies exploring influenza vaccine coverage for this group have generally included ethnic minorities, immigrants and homeless people. [4][5][6] For the purpose of this study, we have defined 'hardto-reach' population as those who do not access healthcare services due to a number of factors, such as being from an ethnic minority, homeless or in financial crisis. This population will invariably overlap with those who are at higher risk of severe influenza due to the conditions outlined prior.…”

“…This is lower than the UK national coverage in the corresponding age group with risk factors for severe influenza (53.2% in those aged 16-64 years, and 74% in those aged 65 years and older). 6 Factors that influence influenza vaccine uptake are complex in hard-to-reach populations and groups at high risk of severe influenza, given these two groups are heterogeneous and they frequently overlap. A survey looking at the determinants of influenza vaccine coverage in the hard-toreach populations in New York City included people from the ethnic minorities group, undocumented immigrants, sex workers and injecting drug users.…”