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Authors' ContributionsMR was responsible of study design and data analysis, with the contribution of CS. FC was the main responsible of data collection, with the contribution of GG. Both GG and CS contributed to data analysis and manuscript preparation.
The present study aims to characterize personal attitudes and knowledge of a sample of Italian Occupational Physicians (OPh) towards Seasonal Influenza Vaccine (SIV) in healthcare workers (HCWs).
In total, 92 OPh (42.4% males, 57.6% females, mean age of 47.3 ± 10.4 years, 50 specialists in Occupational Medicine, 42 specialists in Hygiene and Public Health) were asked about their attitudes towards influenza vaccine, their general knowledge of vaccine practice, their propensity towards vaccines and, eventually, their risk perception about the influenza and influenza vaccine was investigated. A regression analysis was then performed in order to better characterize predictive factors for vaccine propensity.
Influenza was recognized as a vaccination recommended for HCWs in 89/92 of the sampled OPh (96.7%). However, prevalence of misconceptions about vaccines was relatively high, with 26/92 (28.3%) and 24/92 (26.1%) referring vaccinations as eliciting allergic and autoimmune diseases, respectively and identifying lethargic encephalitis (18/92, 19.6%), autism (17/92, 18.5%), diabetes mellitus (15/92, 16.3%) and multiple sclerosis (13/92, 14.1%) as causatively vaccine-related. Propensity towards influenza vaccination found a significant predictor in the general knowledge (beta coefficient 0.213, p value = 0.043), risk perception (beta coefficient 0.252, p value = 0.018) and general propensity towards vaccinations (beta coefficient 0.384, p value = 0.002).
In spite of a diffuse propensity towards SIV, adherence of OPh was still < 50% of the sample. Moreover, sharing of misbeliefs and misconceptions was significant. As knowledge and risk perceptions were identified as significant predictors of vaccine propensity, our results suggest that information and training programs for OPh should be appropriately designed.
Seasonal influenza (SI) is a highly contagious vaccine preventable infectious disease (VPD), which can result in debilitating illness and potentially fatal complications in subjects at risk, representing a major public health problem with a heavy impact on National Healthcare Systems [1, 2]. Because of theirs professional duties, healthcare workers (HCWs) not only are at high risk of contracting SI, but also represent a significant source of transmission and circulation of the viruses in the community [3, 4]. SI vaccine (SIV) is safe and usually well-tolerated [5-8], and evidence suggests that policies involving immunization of HCWs may cost-effectively decrease employee absenteeism caused by SI. Moreover, by preventing its transmission between HCWs and patients, SIV would ultimately improve patient safety and decrease influenza- related morbidity and mortality [2, 9]. Since 1981, the United States Centers for Disease Control and Prevention (CDC) have therefore advised that HCWs will receive SIV [3, 10, 11], and in 2002 also the World Health Organization (WHO) began encouraging annual immunization where supported by national data and capacities, furtherly strengthening its recommendations during the 2009 H1N1 influenza pandemic [2, 5-8]. Nowadays, several European Public Health Authorities, such as the Italian National Health Service (in Italian: Servizio Sanitario Nazionale, SSN), have implemented SIV in HCWs through official recommendations (in Italy: National Immunization Prevention Plan / Piano Nazionale di Prevenzione Vaccinale or PNPV) [3, 7, 12-19]. However, vaccination coverage remains heterogeneous and usually unsatisfactory, with rates well below the minimum target of 75% required by the European Commission, as still ranging from about 15% to 50% in different countries [4, 15, 20-23]. Although Italian data on vaccination coverage among HCWs are not routinely available, recent studied have confirmed an inadequate compliance, suggesting that vaccination rates would have significantly declined since 2009 H1N1 pandemic, being presumptively well below 20% [7, 12 15, 19, 24, 25].
A number of studied have examined specific factors influencing SIV uptake by HCWs, identifying major barriers in system failures (e.g. stock-outs, limited availability of vaccination services in terms of time, places, etc.) and in individual factors such as: doubts regarding the preventive usefulness of vaccines and the rationale for vaccination, lack of knowledge regarding natural infection (i.e. actual risk for HCWs) and its potential consequences, misbelieves about vaccine-related risks and vaccine safety, as well as a diffuse lack of trust in the health policies and in the health authorities that promote them [2, 16, 26, 27]. In facts, a significant share of HCWs still understand SI as a mild illness not requiring a specific prophylaxis, and that contracting the disease is somehow safer than getting the vaccine [2, 16, 18, 25-31]. Collectively, aforementioned factors concur to the definition of vaccine hesitancy (VE), i.e. the continuum between full acceptance of vaccines with no doubts and the complete refusal with no doubts [28-31], and VE would in turn impair proactive behaviors, ultimately contributing to low vaccination rates [2, 16, 18, 25-31].
Occupational Physicians (OPh) are the medical professionals responsible for health promotion on the workplaces , and may actively contribute to overcome false attitudes and misconceptions supporting VE. Moreover, OPh inform the workers about the pros and cons of recommended vaccinations, and may therefore undermine or even remove the mutual misunderstanding between public health professionals and vaccine hesitant individuals, eventually maximizing the consent for vaccination programs . Unfortunately, although numerous studies have assessed knowledge, attitudes and practices (KAP) of specific occupational groups regarding vaccinations, and such interventions have been proven as quite efficient in designing appropriate vaccination campaigns, ultimately improving immunization rates [20, 23, 26, 33-35], KAP of OPh about influenza vaccine have been scarcely investigated [32, 36, 37]. Moreover, as determinants of VE are vaccine-, VPD- and context-specific [28, 29], available evidence from general studies about vaccine acceptance in HCWs and more specifically in OPh are of limited generalizability [36, 37].
The aim of this study, therefore, to assess KAP of OPh about SIV and vaccination policies, including both general and specific recommendations for HCWs, and how attitudes and knowledge relate to these recommendations. Eventually, we attempted to identify areas that may be targeted for improvement through specific informative and educative campaigns dedicated to OPh.
A cross-sectional questionnaire-based study was performed in the second half of 2015, involving OPh operating in the Autonomous Province (AP) of Trento (North- Eastern Italy). Participants were inquired about their KAP towards vaccinations, and more specifically on the SIV. Sampling was performed through convenience, as the initial population included all OPh participating to a seminar on occupational health that took place in the AP of Trento in October 2015 and assisting at least one healthcare provider in the AP of Trento (n = 105, 43.9% of 239 OPh usually operating in the AP of Trento). All participants giving their preventive agreement in the following weeks received a telephonic interview assessing knowledge and attitudes towards SI and SIV in HCWs.
Two specifically formed researchers compiled a structured questionnaire through a telephonic interview. The questionnaire was formulated in Italian (an English translation is presented as the Annex 1), and its test-retest reliability was preventively assessed through a survey on 10 health professionals completing the questionnaire at two different points in time. All questions were self-reported, and not externally validated.
The final questionnaire comprised general demographic information (i.e. age, sex, country of origin) and the following areas of inquiry:
Eventually, participants were asked whether they had received SIV during 2014-2015 winter season. Subjects self-assessed as "not vaccinated" fulfilled a subsequent set of items exploring the reasons for not having been previously vaccinated. In particular, participants were asked whether: (1) they had organization problems (i.e. "not enough time"); (2) they felts themselves as already immunized by previous vaccination campaigns; (3) would prefer recur to alternative countermeasures; (4) are not convinced that IV is useful; (5) have fear of injections or (6) of side effects; (7) they understand vaccination as a mild disease, making therefore useless the vaccine and eventually (8) whether IV is contrary to their personal / religious beliefs.
Before they give their consent, participants were informed that all information would be gathered anonymous and handled confidentially. Participation was voluntary, and the questionnaire was collected only in subjects who expressed consent for study participation. As individual participants cannot be identified based on the presented material, this study caused no plausible harm or stigma to participating individuals.
As the study design assured an adequate protection of study participants, and neither include clinical data about patients nor configure itself as a clinical trial, a preliminary evaluation by the Ethical Committee of the Provincial Agency for Health Services (in Italian: Azienda Provinciale per i Servizi Sanitari, APSS) was statutorily not required.
Two independent researchers, one of whom read the responses from each questionnaire while the other researcher reviewed the entered data, ensured the accuracy of data entry. The primary investigator examined unclear responses to determine the correct answer. We calculated the described indices for general knowledge (GKS), risk perception (RPS) and vaccine propensity (G-PS and IV-PS).
Continuous variables (i.e. age, GKS, RPS, G-PS, IVPS) were expressed as mean ± standard deviation. Categorical variables were reported as percent values. Univariate confrontation between continuous variables was performed through Student's t test for unpaired data, whereas proportions were evaluated through Chisquared test (with continuity correction). Association of dichotomous variables was assessed in univariate analysis through calculation of respective Odds Ratios (OR) with their respective 95% Confidence Intervals (95% CI). Relations between the continuous variables were explored through the calculation of the Pearson productmoment correlation coefficient (i.e. Pearson's r). A logistic regression analysis (SPSS 23) was performed in order assessed the relative influence of personal attitudes and general knowledge on personal propensity to vaccinate. The analyses were controlled for age, sex, qualification. Odds Ratios similarly adjusted for age, sex, country of origin, and qualification (adjOR) were calculated through a binary logistic regression analysis for factors that in univariate analysis were associated with dichotomized propensity ("somehow favorable"/"somehow against" influenza vaccination) and previous SIV at p < 0.150. Significance level was 5%.
While in European Countries vaccination rates of HCWs against SI remain far below the target objective of 75%, still ranging between unsatisfactory rates of 14% and 50% [1, 42, 43], a growing number of authorities have developed initiatives aimed to increase SIV uptake among HCWs . Addressing the factors that explain insufficient adherence of HCWs to official recommendation about SIV has consequently become a growing focus of attention [15, 18, 25, 44-46]. Sound evidences do suggest that HCWs may share with the general population significant fears of side effects, misconceptions about vaccine safety, and even poor knowledge of vaccine's benefits, ultimately leading them to lower vaccination rates [16, 18, 47]. Moreover, a significant share of HCWs would underestimate not only the actual severity of seasonal influenza natural infection, but also their potential role in transmitting VPDs to the patients [3, 4, 10, 18, 23, 26, 48-51].
Despite the growing number of studies performed in recent years, at our knowledge few researches specifically evaluated KAP of OPh: overall, their knowledge of vaccines and vaccine recommendations were not consistently satisfactory [32,36, 37]. Also in our study, OPh were affected by a relatively high prevalence of misconceptions about vaccines : interestingly enough, participants OPh shared false beliefs and misunderstandings about presumptive association between vaccines and autoimmune diseases (i.e. multiple sclerosis, diabetes), and also between certain immunizations and disorders such as autism, subacute sclerosing panencephalitis, and lethargic encephalitis. Worries about such associations were actually raised in the previous decades being then criticized or even largely disproved in the following years [52-54]. Although a significant base of evidence ultimately denies a causality between vaccinations, autoimmune and neuropsychiatric disorders, aforementioned warnings still receive diffuse emphasis on conventional media, remaining very influential on the "new media" (i.e. social media, personal blogs, etc.) [14, 15, 30, 31, 55, 56]. Interestingly enough, a greater share of false beliefs and misconceptions was identified in older subjects: we could tantalizingly suppose that such information gaps may be understood as a consequence of an insufficient continuous medical education and, as risk perception follows the acquisition of the knowledge [32, 60-62]. Such information gaps may in turn explain why the majority of sampled OPh identified influenza as a substantially indolent disease, and similarly around a quarter of the sample underestimated the probability for HCWs to develop seasonal influenza natural infection (26.1%). Actually, some international reports suggest that HCWs may avoid SIV as they understood its potential adverse effects as more severe and frequent than the avoided consequences of the natural infection [3, 18,20, 43].
Although in our sample doubts inherent vaccine safety were somehow reduced, as 90.2% of participants perceived probability of adverse effects as "almost zero" to "rather low", and the main reason referred by the participants to have not been vaccinated against SI was the lack of time, OPh with a better trust on the proven efficacy of vaccines, as defined by general knowledge test, more frequently reported vaccination against seasonal influenza (adjOR 3.999 95% CI 1.245-12.84), whereas no significant effect was found on individual vaccine propensity. Regarding the organization issues referred by participants, it should be recalled that Italian OPh are HCWs that usually work as private practitioner: in other words, their adherence to official recommendation towards SIV could have been significantly impaired by factors other than personal beliefs and misconceptions, as the limited availability of vaccination services [4, 11, 14-19].
Similarly, we found a significant correlation between GKS and RPS (r = 0.317, p = 0.002), and such correlation was not unexpected [32, 36], as well as that of both cumulative score with propensity towards SIV (r = 0.492, p < 0.001 and r = 0.280, p = 0.007, respectively). Consistently with previous researches in KAP in HCWs towards vaccinations [4, 11, 14-18, 32, 36], all factors presumptively involved in the building up of personal attitudes (i.e. GKS, G-PS, RPS) were then identified as significant predictors of the propensity towards SIV. In other words, a greater knowledge (i.e. less misconceptions and/or less personal attitudes guiding the vaccine decisions) of vaccine and vaccine-related disorders on the one hand, and a more accurate risk perception of SI on the other hand were associated with a better attitude towards SIV. In effect, there is a considerable evidence that a better awareness and a greater trust in vaccines increase the individuals' propensity to be vaccinated, and in OPh the latter would be in turn associated with a greater propensity to perform and promote vaccinations on the workplaces [14-16, 32, 67, 68]: in other words, any information gap in OPh would ultimately lead to diffusely hold and diffuse doubts or false beliefs about vaccines rejection of some vaccines [26, 56-59], being significant drivers of a more extended VE in HCWs and in turn in the general population with devastating consequences [32, 36].
However, it should be stressed that several factors not necessarily included in the knowledge and risk perception assessment contribute to building up vaccine confidence (and conversely VE) : although adhesion to the official recommendations is usually characterized as weak driving factors [18, 25, 28, 29], attitudes of OPh may be significantly influenced by concerns about potential legal consequences of their actual implementation. In other words, participants may have reported behaviors unrelated with actual knowledge and risk perception, exhibiting a sort of "social desirability bias", i.e. the tendency of research subjects to give socially desirable responses instead of choosing responses that are reflective of their true feelings [64, 65]. Also the higher propensity towards SIV in specialists in Occupational Medicine than in specialists in Hygiene and Public Health, the latter assed as a dichotomous attitude (OR 12.000 95% CI, 3.964-36.33) and as a cumulative score as well (IV-PS, 4.4 ± 0.8 vs. 3.1 ± 1.4, p < 0.001), and better performances in both the general knowledge tests (7.0 ± 3.0 vs. 4.6 ± 5.1, p = 0.008) and in the assessment of the risk perception (9.6 ± 7.4 vs. 5.1 ± 9.3, p = 0.011) may be similarly explained. These results were otherwise unexpected, as vaccinology represents a cornerstone of the core curriculum of specialization courses in Hygiene and Public Health, and a significantly higher share of positive attitudes and appropriate knowledge was previously reported in residents in Hygiene and Public Health .
As risk perception may be understood as an intermediate step between knowledge and the developing of an attitude [32, 60-62], a self-reported positive vaccination status was unsurprisingly associated with a positive attitude towards vaccination (adjOR 5.806 95% CI 1.242-27.15). In this regard, although vaccination rate was well below 50% (43/92, 46.7%), our survey is consistent with previous studies on HCWs: despite data on European HCWs clearly show a very low compliance towards SIV, physicians have been usually described as more receptive to influenza vaccination than other HCWs, ultimately exhibiting similar vaccination rates [9, 18].
Several major limitations of the study have to be addressed. For instance, we assessed a sample of relatively small size, gathered through convenience sampling and a regional basis. As Italy is highly heterogeneous in term of vaccination rates and vaccine acceptance, our sample may therefore not represent the whole Italian OPh populations . Second, our sample was drawn from a very selected population that presumptively included OPh more sensitive to medical education themes (i.e. subjects participating to a Continuous Medical Education course): a significant selection bias cannot therefore be ruled out, ultimately suggesting that our sample overestimated actual vaccine acceptance of the parent occupational group. Moreover, as our questionnaire did not investigated the information sources from which assessed knowledge and elements of risk perceptions were drawn, we are unable to evaluate whether these results are a serendipitous association in the context of a small sample, or rather the actual consequence of a different post-graduate formation, and this may be acknowledged as another weakness of this study. Generalization of our results may be furtherly compromised by the very same design of the survey. In other words, not only participants may have overrated their actual vaccine propensity and similarly assessed the items of the general knowledge test in terms of "social desirability", but we cannot rule out a substantial lack of specificity in the recalling of vaccination status .
In conclusion, our results are consistent with previous reports on HCWs and with the limited available evidence on OPh. More specifically, the majority of OPh were somehow favorable to SIV, but a significant share of misbeliefs and false knowledge were also identified. As knowledge and risk perception were identified as significant predictors of vaccine propensity, our results suggest that that filling information gaps may significantly improve vaccine propensity of OPh, and possibly increase the vaccination rates in HCWs and, in turn, in the general population. Moreover, our results suggest that a significant share of HCWs may benefit from more flexibility, in term of time and accessibility, by healthcare providers performing SIV, and in particular with vaccination services. Their better interaction with OPh would be also useful in order to address personal misconceptions and target false beliefs, ultimately increasing the awareness of the potential of SIV, in the HCWs and, subsequently, in the general population.
The authors thank the subjects whose participation made this study possible.
All person who meet authorship criteria are listed as authors, and all authors certify that they have no affiliation with or involvement in any organization or entity with any financial interest, or non-financial interest (such as personal or professional relationship, affiliation, knowledge of beliefs) in the subject matter or material discussed in the manuscript.