Coronavirus (COVID-19) and flu vaccination programme: user journeys and experiences

4. Getting a flu vaccination

Key points

• Participants had typically been aware of the flu vaccination programme for a number of years.
• Key information sources included: NHS invitation letters, GPs and nurses, posters in GP surgeries and pharmacies, television advertising and workplace communications (particularly NHS employees).
• Personal health risk was a key factor influencing decisions on the flu vaccine.
• Other factors acting as both drivers and barriers to receiving a flu vaccination included: perceived effectiveness of the vaccine; views on its safety and side effects; Covid-19 and flu being in circulation at the same time.
• Similar to practical experiences of the Covid-19 vaccination, experiences of receiving the flu vaccination were largely positive
• Views on getting the flu vaccination at the same time as the Covid-19 vaccination were mixed. It could be appealing as it saved time and was convenient. However, concern about increased side effects could be off-putting.

This chapter explores participants' experiences of the flu vaccination programme, first looking at information and awareness of the programme before moving on to consider motivations and barriers to receiving a flu vaccination and practical experiences of doing so. Comparisons with views and experiences of the Covid-19 vaccination are drawn out throughout, as well as being summarised in Figure 4.1.

It should be noted that questions on the flu vaccine were only asked to those who were eligible to receive it through the NHS, typically those with a health condition, caring responsibilities or working in NHS/other care roles (44 of the 81 participants). All who had received a flu vaccination had also received at least one dose of the Covid-19 vaccine.

Figure 4.1: Flu and Covid-19 comparisons

Figure 4.1 describes attitudes and behaviours relating to the flu vaccine, compared to the Covid-19 vaccine.

Accessing information: less likely to seek out information.

Trust in information: less scepticism, conspiracy theories not mentioned.

Trust in the vaccine: Greater trust due to longevity, previous personal experience of receiving it

Perceived health risk as a motivator: Primary reason for receiving flu vaccine. More limited to those with underlying health conditions.

Concerns around side effects: More about short-term side effects than potential long-term, unknown risks from Covid. Known if had in the past.

Experience of receiving the vaccine: Equally positive practical experiences. Side effects less severe.

Accessing information

This section deals with factors that fall predominantly under the 'capability' element of COM-B as it considers the participants' ability to access and understand information in order to make an informed decision on whether to get the flu vaccination.

It was typical for participants to have been eligible for an NHS flu vaccination for a number of years. They were therefore not always able to say when or how they first became aware of the programme. However, a number of information sources relating to the flu vaccination programme were mentioned, including: NHS invitation letters, GPs and nurses, posters in GP surgeries and pharmacies, television advertising and workplace communications (particularly NHS employees). Participants also described specific circumstances that had led them to become aware of it, for example becoming eligible as a result of being pregnant, taking on caring responsibilities or through their children becoming eligible.

In contrast to the Covid-19 vaccine, participants did not typically seek out information on the flu vaccine beyond that included in the sources noted above. They tended to be content with the information available to them and there was little evidence of it being a topic discussed with family or friends or on social media. There also appeared to be greater levels of trust in information on the flu vaccine, largely due to its longevity.

Motivations and barriers to engaging with the flu vaccination programme

This section deals with factors that fall predominantly under the 'motivation' element of COM-B, i.e., the decision-making processes involved in choosing whether or not to receive the flu vaccination.

Among those eligible for an NHS flu vaccination, experiences ranged from receiving it every year, having it just once or infrequently to never having taken up the offer. There were also those who had only recently become eligible due to changes in their circumstances, for example, becoming a carer. Health risk, both personal and to others, was the main factor influencing engagement with the flu vaccination programme. The combination of both Covid-19 and flu being in circulation at the same time was a further determining factor.

Health risk

Personal health risk was a key factor influencing decision making around the flu vaccination. Participants with underlying health conditions, and particularly respiratory conditions such as COPD and asthma, which they felt increased their risk of being more seriously ill or dying from the flu, tended to receive the flu vaccine annually and feel that this was a key measure in protecting their health.

"I have to get it because of my illness, because I can't afford to catch it, because I can't breathe as it is already."

Participant, health condition or disability, white Scottish, man, 40+, 3+ Covid-19 vaccinations

Others did not have the same fears about becoming seriously ill with flu but felt it was wise to take up the offer due to having immune systems weakened by their health condition or disability (for example diabetes, cancer or Downs Syndrome).

Health risk was also a motivator for those eligible for the flu vaccination because of being a carer or working in the NHS. Participants described a desire to avoid catching something that would make them feel unwell (particularly if they felt working in a hospital exposed them to a greater risk of catching viruses), both for their own health and to protect the health of others they cared for at home or as part of their job.

On the flipside, a perceived lack of personal health risk could act as a barrier among those without health conditions, with participants feeling that flu did not pose a significant risk to their health and that there was little reason to have it.

"[I haven't had the flu vaccination because] … I just feel my immune system is quite good. I don't catch many colds. I'm not sure but I will not say I will never get it"

Participant, health condition or disability, White Polish, woman, 40+, SIMD2, 3+ Covid-19 vaccinations

There was a view among this group that flu was similar to a cold, perhaps indicating a misunderstanding of how serious it can be.

Finally, there were participants who had not actively decided against the flu vaccination but displayed a degree of indifference, illustrating that they did not view it as a high priority in terms of their health. This included those who believed they should be eligible but had not received a letter and those who had missed their original appointment and had not got around to making another.

Perceived effectiveness

In weighing up whether to have the flu vaccine, views on its effectiveness were also factored in. There was mention that the vaccine is not guaranteed to prevent against all possible variants as well as reflection on past experiences. On the one hand receiving the flu vaccine regularly and not having had flu could instil confidence that the vaccine was working. On the other hand, though, experiences of having flu despite being vaccinated could lead participants to question the need to have it, particularly if they did not perceive themselves to be at high risk from flu.

"When I got my vaccine I ended up getting the flu anyway, so it didn't actually prevent me from getting the flu, so I thought, well, I had a dead arm for a few days, what is the point in going and getting it if you're going to catch the flu anyway, it's not protecting you 100 per cent and there is different variants of flu, so until that winter they don't actually know what the variant of flu is that year. So, it is kind of hard to say whether the flu vaccine is effective."

Participant, Pakistani, woman, 40+, SIMD1, no Covid-19 vaccinations

Safety and side effects

For participants who received the flu vaccination regularly, the decision was generally an easy one – it had become almost routine and was not something they gave much thought to each year. Familiarity with the vaccination and previous experience of getting it without any problems or serious side effects had built trust and confidence in the safety of the vaccine. These participants did not tend to have any concerns about having it, and, indeed, noted they would feel more concerned if they were not able to receive it for any reason.

"I don't really think about it now because I have been having it for that long, I just believe it is part of my life when it comes to the end of the year, the time I get my flu vaccination again."

Participant, Indian, man, under 40, carer, SIMD1, 3+ Covid-19 vaccinations

Concerns about the side effects of the flu vaccine could, however, act as a barrier to uptake, particularly among participants with underlying health conditions. Typically, participants had worries about becoming ill with flu or flu-like symptoms after having the vaccine which stemmed from previous personal experiences of having the flu vaccine or the experiences of others they knew. The decision could be a difficult one for these participants as they had to weigh up the risk of having the vaccine against the risk of getting flu.

"I had the flu really, really, bad, probably five years ago, after the flu jag. That year I had the flu really, really, bad. Never had it like that before and I blame the flu jag. I thought 'okay, I'm not having this ever again'. I get offered it every year, I have refused it."

Participant, Pakistani, woman, 40+, SIMD1, parent, 2 Covid-19 vaccinations

In contrast to the Covid-19 vaccine, concerns about side effects of the flu vaccine tended to be confined to these flu/flu-like symptoms rather than related to more serious or long-term effects. As discussed in Chapter 2, the speed at which the Covid-19 vaccine had been developed and introduced, in contrast to other vaccines, was a key reason for this. As the following quote illustrates, even where participants had concerns about getting the flu vaccine for the first time, they were not seriously concerned about negative consequences, in the same way they could be about the Covid-19 vaccine.

"It was difficult, oh, the first one was of course, oh aye, I kept thinking to myself, does it work? […] One of the guys I worked with, he got his and he caught it [flu], so it makes you think, 'why bother getting it if it's not going to work?'. But I still went for it anyway, I ended up going for it, see they didn't tell you that you were going to die with getting it, because nobody ever died, nobody dies with that jag, not that I know of anyway."

Participant, health condition or disability, white Scottish, man, 40+, 3+ Covid-19 vaccinations

The presence of Covid-19

The presence of Covid-19 acted as both a motivating factor and a barrier to receiving the flu vaccine during winter 2021/2022. On the one hand, concern about the dual risk from both viruses being in circulation prompted some participants who did not regularly have the flu vaccine to do so. This included those who cared for a vulnerable family member, those who were pregnant at the time and those, described above, who had not received the flu vaccine in recent years due to negative past experiences of side effects.

"At a point I made a decision to stop taking the flu vaccine because any time I had the flu vaccine that winter I had terrible flu. The one year I didn't have it, I didn't have any flu throughout the winter season, so I made up my mind I wasn't going to have the flu vaccine ever and up until last year I hadn't had the flu vaccine for at least four years. So, with the Covid and with all the pressure this is the time to have the flu vaccine because it could be worse with this and that. I was like, 'okay, I give up, I give in' [and got the flu vaccine]"

Participant, Black African, woman, 40+, parent, carer, 3+ Covid-19 vaccinations

One participant who was offered the flu vaccine as she was pregnant also noted the lack of exposure to germs, due to isolation, as a factor in her decision to have the flu vaccination.

"I decided to take it as a precaution, because I felt that maybe, you know, it is going to help me not to get sick when I'm pregnant. Especially like with Covid you isolate yourself all the time, so you don't have exposure to germs in the amount of, you know, your usual life pre-Covid. […] and I was thinking maybe I should take the flu vaccination because somebody will sneeze on me and I will be instantly sick because of, you know, being isolated all the time and escaping from all kinds of germs."

Participant, health condition or disability, White Polish, woman, under 40, SIMD2, parent, 3+ Covid-19 vaccinations

On the other hand, there were instances of the Covid-19 vaccination programme discouraging people from receiving a flu vaccine when they would otherwise have considered it. For example, for one participant, distrust of the Covid-19 vaccination (largely concerning risk of blood clots) led her to refuse her flu vaccination due to a worry that it could be contaminated with the Covid-19 vaccination (as both were being delivered in the same place).

Concern around the number of vaccines received in a short space of time was a further influencing factor. One participant who was pregnant at the time of the interview described having decided not to have either her Covid-19 booster or flu vaccination while she was still pregnant as she felt she had taken enough vaccines while pregnant (first and second Covid-19 vaccines).

Experiences of receiving a flu vaccination and practical considerations

This section considers the practical experiences of being invited for and receiving a flu vaccination, largely relating to the opportunity element of the COM-B behaviour change model.

Similar to experiences of the Covid-19 vaccination, experiences were largely positive. For participants who made the decision to get the flu vaccination at the same time as their Covid-19 vaccination (discussed below), the practical experiences of this vaccination appointment are covered in Chapter 4.

Typically, participants had been invited to have their flu vaccination by letter (including in their letter for the Covid-19 booster). Other invitation methods included text message and via work for those eligible because of their job. As described above, there were participants who believed they were eligible (due to having had the flu vaccination in other years) but had not received a letter.

Views on getting the flu vaccination at the same time as the Covid-19 booster vaccination were mixed. It could be appealing as it saved time and was convenient - in some cases, participants had received a letter inviting them to receive both at the same appointment while, in others, they had gone expecting to receive their Covid-19 booster and had been offered, and accepted, the flu vaccination while there. There were also participants who said they would have chosen to have both vaccines at the same appointment had this been offered to them.

However, concern about increased side effects could be off-putting. This included both minor side effects (both arms being sore and out of use at the same time) and being more seriously ill afterwards (based on experiences of others). Indeed, one participant who made the decision to receive both vaccinations together had experienced worse side effects compared to his first and second Covid-19 vaccinations which had made him uncertain whether he would get the flu vaccination in the future. Generally speaking, however, participants did not report major side effects of the flu vaccination.

Participant story: Julia

Julia is from Poland and has lived in Scotland for many years. She works full-time in an office and has a 10-year-old child. She found the pandemic very frightening and felt that it was important that she do her own research about the vaccines. She was concerned about how quickly the Covid-19 vaccine had been developed and worried about side effects. However, she decided to get it to protect herself and her daughter. She had also talked to her family in Poland who had all been vaccinated without problems. The travel restrictions were another reason (although less of a factor) because she wanted to visit home at some point. Her Covid-19 vaccination appointments all went smoothly and were convenient for her.

She was more nervous about the flu vaccine because she had a bad reaction to it a few years ago. She was offered the vaccine through her work, and a nurse came in to vaccinate her colleagues. This gave her the opportunity to talk to the nurse in about her decision – she wasn't planning on getting it, but the nurse reassured her that the side effects were unlikely to happen again and that it was very low risk. This helped her decide to accept the flu vaccine. She had no reaction and felt like she had made the right decision. Her experience with the Covid-19 and flu vaccinations is outlined in the user journey below.

User journey: Julia

This is the user journey of Julia, a woman with history of reactions to flu vaccine.

• Influences on her decision to get the vaccination – Found information on the news (for example the BBC) and social media (although you can't believe everything you read). A colleague refused the vaccine and was hospitalised with Covid-19.
• Motivations to get 1^st vaccination – Health risk to herself and others, travel restrictions.
• 1^st vaccination experience – Doesn't like needles but otherwise no concerns. Vaccinated at venue near work. Very efficient, lots of information, short wait times. No side-effects.
• Motivations to get 2^nd vaccination – Same reasons as before (health risk to herself and others, travel restrictions).
• 2^nd vaccination experience – Different location, near home. Smaller venue but still well-organised. Walk-in clinic.
• Motivations to get 3^rd vaccination – Same reasons as before (health risk to herself and others, travel restrictions).
• 3^rd vaccination experience – Walk in appointment, suited her well. In her own words: "Maybe I'm lucky, I had a good experience with all of them".
• Motivations to get flu vaccination – To protect herself, positive interaction with nurse.
• Flu vaccination experience – Nervous due to past side effects. Has not had it for a few years since had a bad reaction one year. Reassuring conversation with nurse motivated her to get it and it was all fine.

Participant story: Anya

Anya lives with her husband and three children in a small town. Two of her children have behavioural issues which were exacerbated by lockdowns, and she found the it was difficult to maintain a routine for her children during the pandemic. She is also an unpaid carer to her mum, who has a long-term health condition and lives nearby.

She first heard about the Covid-19 vaccines in the news, and then was invited to be vaccinated herself. She chose to get vaccinated as she was very scared of catching Covid-19 and wanted to be able to travel safely to visit her family. She also wanted to minimise the risk that she would pass it on to her mum. She had some concerns about how quickly it had been developed, but never had any real doubt that she would accept it. All her Covid-19 vaccination appointments went smoothly and were relatively convenient – the only thing that could have been better would be if they were in her town, rather than having to travel to a nearby village.

This year, Anya received a letter from the NHS inviting her to get a flu vaccination. This was the first year that she was eligible, as she has only recently become a registered carer for her mother. Her reason for accepting the vaccination was to protect her mother. Given her mum's health conditions, it was recommended that Anya be vaccinated against flu to avoid passing it on. The Covid-19 pandemic also affected Anya's decision – she was particularly worried about the possibility of her mum catching flu and Covid-19 together, and she therefore accepted the flu vaccine to minimise this risk. The flu vaccine appointment worked well, it was in a local pharmacy, and she knew the staff there. However, it would have been better if she had been given the option to have it together with her Covid-19 booster.

Anya's experience is illustrated in the user journey below.

User journey: Anya

This is the user journey of Anya, an unpaid carer who was influenced by the Covid-19 pandemic to get a flu vaccine.

• Influences on her decision to get the vaccination – Wanted to be able to travel safely. In her own words: "You just take the NHS advice because you trust them, well I do anyway."
• Motivations to get 1^st vaccination – Health risk to herself and her family, desire to travel.
• 1^st vaccination experience – Some concerns about side effects and needles. Got a taxi to venue in nearby village. Positive interactions with staff, all felt safe. No side-effects.
• Motivations to get 2^nd vaccination – Same reasons as before (health risk to herself and her family, desire to travel).
• 2^nd vaccination experience – Same venue, very well-organised. Side effects worse this time – sore, heavy head that wasn't helped by painkillers.
• Motivations to get 3^rd vaccination – Same reasons as before (health risk to herself and her family, desire to travel).
• 3^rd vaccination experience – Walk-in appointment. Venue a bit further away but she got a lift. Didn't have to wait at all, all went fine.
• Motivations to get flu vaccination – To protect her mum from getting flu.
• Flu vaccination experience – Newly eligible as carer to her mum. Was worried about her mum catching Covid-19 and flu together – one is bad enough. Convenient and straightforward.