Eating steamed pears, having a soothing massage or bathing in a herbal mixture are just some of indigenous health practices used by older people to ward off or treat influenza, according to research published in the October issue of the Journal of Advanced Nursing.

Other traditional measures discovered by nurse researchers at the Hong Kong Polytechnic University included being rubbed with a coin, eating cheese, yoghurt and honey and having warm drinks made with ginger or lemon.

The team surveyed nine countries to find out why so many of them were failing to meet the 75 per cent annual influenza vaccination rate recommended by the World Health Organization. They found that people who chose not to be vaccinated were more likely to rely on indigenous health practices - together with good general health and hand hygiene - than those who decided to be vaccinated.

"Annual flu epidemics severely affect three to five million people worldwide every year and cause up to half a million deaths, with most deaths in industrialised countries occurring in people over 65" says co-author Professor Samantha Mei-che Pang from the University's School of Nursing. "That is why it is so important to find out why some older people have the annual flu vaccine, while others decide not to."

The range of countries chosen by the researchers represented different cultures, healthcare financing systems and flu vaccine uptakes. Healthcare is dominated by the private sector in Indonesia and China, while Greece, Turkey and South Korea all operate a national health insurance system. The UK and Canada have national health systems funded by taxation and the health systems in Brazil and Nigeria rely heavily on the private sector.

A series of focus groups were held with vaccinated and unvaccinated older people aged 65 plus and seven countries submitted completed questionnaires providing demographic data on 172 participants. This showed that two-thirds of the people who took part had been vaccinated, with vaccination rates highest in Canada (93 per cent) and lowest in Nigeria (31 per cent). Other countries ranged from 44 per cent to 82 per cent.

The team looked at the attitudes of the vaccinated and unvaccinated people in each group and this provided useful clues about what had influenced their decision.

People made the decision to be vaccinated if they:

* Felt existing health conditions made them vulnerable.

* Viewed flu as very contagious and dangerous, having experienced complications themselves or seen it in others.

* Had experienced no, or minimal, side effects from previous vaccinations and less severe symptoms if they thought they had contracted flu after having the vaccine.

* Recognised that the cost of the flu vaccine was lower to health services than the cost of treating someone who had contracted flu.

* Didn't want to pass the virus onto other family members, like grandchildren.

* Were influenced by what was normal practice in their country and among their circle of friends.

* Had easy access to a local centre providing the vaccine.

* Received reminders that they should be vaccinated, from healthcare professionals, the media or friends and neighbours.

* Were able to afford the vaccine if it was not provided free by their healthcare system.

People who did not have the flu vaccine said they:

* Didn't see themselves as vulnerable.

* Felt less convinced that the vaccine was effective after negative reports from others about its efficacy and side-effects.

* Felt that it was sufficient to take preventative measures, such as leading a healthy lifestyle, with sufficient exercise, a good diet, good hand hygiene, keeping warm and staying away from germs.

* Were more likely to trust indigenous health practices, such as special drinks, food or other traditional remedies.

"Our findings support the growing evidence that older people are much more likely to be vaccinated against flu if they feel vulnerable, see flu as a threat and believe that the vaccine will be effective with little, or no, side effects" says Professor Pang.

"It also revealed a finding that we do not believe has been observed in previous studies: that those who distrust the vaccine's effectiveness are more likely to rely on healthy lifestyles, good hand hygiene and indigenous health practices to protect them from flu.

"Cost was also a factor in countries where free healthcare was not available and some people did not have easy access to a local centre offering vaccinations. The importance of providing regular reminders was also important, as was creating a culture where receiving an annual flu vaccine was the norm for older people."

The study, which was funded by the International Council of Nurses, includes further details on each country's participants, together with quotes from the focus groups.