Knowledge, attitudes and perceptions of health professionals in relation to A/H1N1 influenza and its vaccine.

OBJECTIVE: To determine the intention of health professionals, doctors and nurses, concerning whether or not to be vaccinated against A/H1N1 influenza virus, and their perception of the severity of this pandemic compared with seasonal flu.
MATERIAL AND METHODS: A cross-sectional study was carried out based on an questionnaire e-mailed to health professionals in public healthcare centres in Vitoria between 6 and 16 November 2009; the percentage of respondents who wanted to be vaccinated and who perceived the pandemic flu to carry a high risk of death were calculated.
RESULTS: A total of 115 people completed the questionnaire of whom 61.7% (n=71) were doctors and 38.3% (n=44) were nurses. Of these, 33.3% (n=23) of doctors and 13.6% (n=6) of nurses intended to be vaccinated (p=0.019). Even among those who considered themselves to be at a high risk, 70.6% (n=48) of doctors and 31.7% (n=13) of nurses participating in the study (p=0.001) planned to have the vaccination.
CONCLUSIONS: Most health professionals, and in particular nurses, had no intention to be vaccinated against A/H1N1 influenza virus at the beginning of the vaccination campaign.

Many international organisations have highlighted the importance of vaccination against seasonal flu for health professionals1–(4). The recommendation is based on various factors such as the increased risk of complications associated with infection in patients in at-risk groups, the tendency to go to work despite flu symptoms, and the high rates of transmission among colleagues. All these elements translate to an increase in costs and deaths.

In fact, it has been demonstrated that the vaccination of health professionals is associated with a decrease in the number of deaths of patients attended at home and of patients with high-risk medical conditions5. Despite several studies having demonstrated the multiple advantages of vaccination, health professionals are not keen on being vaccinated: it has been estimated that overall only between 40 and 50% of health professionals are vaccinated against the seasonal flu virus6, (7), and these rates are even lower among nurses8–(10).

Many reasons have been put forward for not being vaccinated: fear of adverse reactions, underestimation of severity of the flu epidemic, lack of time and doubts concerning safety, among others11–(14). Despite this, it seems that among health professionals who are better informed and know the risk factors more tend to accept the vaccination, so a deeper understanding of the vaccine may help to increase willingness to be vaccinated13–(17).

In 2009, the seasonal flu vaccination campaign was preceded by that of the A/H1N1 flu virus. Since the outset, the A/H1N1 virus has raised great concern in society, given that it is highly infectious, more so than the seasonal flu virus18 and that the prevalence is higher among children19.

Given these factors, vaccination against this type of virus is particularly important. In this context, it is essential to remember that any preventive measures, including vaccines, are ineffective without the collaboration of the population and health professionals20–(23). Adherence to recommendations of this sort is determined by perception of the level of danger5, and of the effectiveness of the measures21, (24). In short, the perception of danger and the understanding of health professionals of the A/H1N1 flu virus may directly affect acceptance of and adherence to these measures and influence the perception of the general population25, (26).

For these reasons, the aim of this study was to determine the intention to be vaccinated against A/H1N1 flu virus among health professionals in relation to levels of understanding, attitudes and perception of risk just before the vaccination campaign at the peak of the epidemic.

Materials and methods

An observational cross-sectional study was carried out among health professionals of the Basque Health System in Vitoria-Gasteiz.

Data collection started on 6 November, coinciding with the peak of the A/H1N1 virus epidemic in the Basque Country, and ended on 16 November, when the vaccination campaign was launched in our autonomous region, despite the fact that the expected sample size had not been reached.

The questionnaire was sent by email to doctors (n=900) and nurses (n=1,326) of the acute care public hospitals of Vitoria-Gasteiz (Txagorritxu and Santiago) and primary care health centres in Araba. They were given the option of answering electronically or by post, sending the questionnaire to the Research Unit, by internal mail within the Basque Health Service/Osakidetza.

The data collected in the survey were entered into a dedicated computer database created using Microsoft Access software.

Study variables

A questionnaire based on that used by Lau et al.20 was produced consisting of 28 questions that gather information concerning views on vaccination against A/H1N1 virus and the perception of risk (Appendix 1).

Questions were asked to assess the attitude of professionals towards vaccination against A/H1N1 flu virus both if it were free of charge and if it had a cost of €10. There were also questions concerning the safety and effectiveness of the A/H1N1 flu vaccine, and research undertaken to produce the vaccine. The response categories were ‘yes’, ‘no’, and ‘don't know/no opinion’, the latter leading to classification as undecided.

Lastly, data related to understanding of the routes of transmission, the perception of risk associated with the virus, and the comparison of A/H1N1 flu with seasonal virus were collected in the final section of the questionnaire.

Analysis of the results

Descriptive statistics were calculated for the main characteristics of the sample. The main outcome was assessed by calculating the percentage of doctors and nurses who had the intention to be vaccinated against the A/H1N1 flu virus, compared with those who did not intend to be vaccinated, in the cases of the vaccine being free and of having to pay for it (€10). Any association between intention to vaccinate and sociodemographic variables including age, sex, level of education, civil status, employment status and understanding of the routes of transmission was explored using the Chi square test and p for linear trend for ordinal variables. In addition, the intention to be vaccinated was calculated as a function of prior behaviour, namely, whether or not they had previously been vaccinated against the seasonal flu virus. The analysis of the main variables (intention to vaccinate against the seasonal and A/H1N1 flu viruses, having previously been vaccinated against seasonal flu, perception of risk, and doubts concerning the effectiveness and safety of the vaccine) were adjusted for age and sex. We considered a level of significance of α=0.05. Statistical analysis was carried out using the Statistical Package for the Social Science (SPSS, version 16) for Windows.

Ethical approval

The study was approved by the Clinical Research Ethics Committees of Txagorritxu and Santiago Hospitals.

Results

General characteristics

Of the 2,226 emails sent (900 to doctors and 1,326 to nurses), 115 questionnaires were returned completed, of which 71 (61.7%) and 44 (38.3%) were received from doctors and nurses, respectively. The sociodemographic characteristics of the two groups are shown in Table 1. Overall, 64.3% (n=74) of the sample had been vaccinated against the seasonal flu at some stage. This percentage was higher (p=0.018) among doctors (71.8%, n=51) than nurses (52.3%, n=23).

Table 1

Sociodemographic characteristics

n=115	Doctors (n=71)	Nurses (n=44)
Sex
Male	29 (40.8%)	6 (13.6%)
Female	42 (59.2%)	38 (86.4%)
Age
Media±SD	42.5±9.9	43.3±10.1
≤30 years	10 (15.4%)	6 (14.3%)
30–65 years	55 (84.6%)	36 (85.7%)
Marital status
Single	17 (25.4%)	13 (29.5%)
Married/couple	50 (74.6%)	31 (70.5%)

Attitude towards vaccination against A/H1N1 influenza virus

A total of 33.3% (n=23) of doctors had the intention to be vaccinated against the A/H1N1 flu virus, compared with 13.6% (n=6) of nurses (p=0.023). These percentages were even lower if the vaccine was not free (€10), both among the doctors (27.5%; n=19) and the nurses (6.8%; n=3).

Among those who considered themselves to be at high risk of contracting A/H1N1 flu, 70.6% (n=48) and 31.7% (n=13) of doctors and nurses, respectively, indicated that they would be vaccinated. There was a statistically significant difference between the two groups, doctors and nurses (p=0.002).

Among the nurses, no significant difference was detected in intention to be vaccinated between those who had (n=4; 11.4%) and had not had the seasonal flu jab previously (n=5; 11.4%, p=0.166). Likewise, intention to be vaccinated was not significantly higher among doctors who had been previously been vaccinated at least once against the seasonal flu virus (n=51), 41.2% (n=21, p=0.126) expressing an intention to receive the H1/N1 vaccine.

Acceptance of the A/H1N1 influenza virus vaccine and perception of its effectiveness

A total of 69.8% (n=30) of the nurses who participated objected to being vaccinated, while this figure was 48.5% (n=33) among the doctors (p=0.04). Significant differences were also found between the groups with regards to the perception of effectiveness of the vaccine. Among respondents, 63.3% (n=38) of the doctors considered that the vaccine was effective, compared with 35.1% (n=13) of the nurses (p=0.044). Even among healthcare workers who trusted in the effectiveness of the vaccine (n=51), more than half did not intend to be vaccinated (n=26; 51%).

Understanding of the A/H1N1 pandemic and routes of transmission

With regards to the routes of transmission, 74.6% (n=53) of doctors and 75% (n=33) of nurses were properly informed. Among these, 65.1% had obtained the information through colleagues, while 20.9% cited the media, and the remaining respondents had acquired the knowledge from other sources.

Perception of risk of infection and severity of the flu

Doctors had a higher perception of risk of infection by A/H1N1 influenza virus than nurses. They considered that they, and their own families and the general population, were at high risk of becoming infected (p<0.05). Data regarding this section of the questionnaire are shown in Table 2.

Table 2

Do you think there is a high risk of suffering from swine flu

		Yes (%)	No (%)	p
You?	Doctors	54 (78.3)	15 (21.7)	0.013
	Nurses	26 (59.1)	18 (40.9)
Own family?	Doctors	58 (84.1)	11 (15.9)	0.01
	Nurses	28 (63.6)	16 (36.4)
General population?	Doctors	56 (81.2)	13 (18.8)	0.031
	Nurses	25 (56.8)	19 (43.2)

With regards to mortality, 68.1% (n=47) of doctors and 79.1% (n=34) of nurses thought that, in 2009, one to 10 people were going to die due to this type of flu in the local area (Vitoria-Gasteiz). On the other hand, 14.5% (n=10) and 16.3% (n=7) of doctors and nurses, respectively, thought that nobody was going to die, whereas 14.5% (n=10) of doctors and 4.7% (n=2) of nurses thought that between 10 and 50 individuals (p=0.247) would die.

A total of 41.4% (n=29) of doctors and 45.5% (n=20) of nurses believed that the harm caused by the A/H1N1 flu virus was similar to that of the seasonal influenza virus (p=0.015), while 43.7% (n=31) of doctors and 59.1% (n=26) of nurses thought that A/H1N1 flu would have a much lower rate of mortality than seasonal flu (p=0.17).

Discussion

The primary objective of this study was to determine the intention of health professionals to be vaccinated as well as their perception of the severity of the infection caused by the A/H1N1 influenza virus, as investigated by other researchers13, (15, 16, 27–29), in relation to this and other pandemics associated with various subtypes of the influenza virus. A total of 2,226 questionnaires were sent of which just 115 were returned completed (5.2%). This overall percentage is lower than that achieved in other studies12, (15, 25, 26) and in other projects carried out in the same area by this research team23, though the rate of response from nursing staff was similar to that obtained by other researchers2, (3). The overall low rate of response may be due to the short window of time during which questionnaires were accepted, given the importance of it being completed before the vaccination campaign began.

The overall percentage of those vaccinated against the seasonal flu at least once before was higher than that observed in other studies30, though similar values to those reported elsewhere were found for nurses31, who, in general, are less keen to be vaccinated5, (6). The overall higher rate may be due to the fact that the vaccine is offered for free in the centres themselves, which facilitates access and hence tends to increase the number of staff vaccinated13. Nevertheless, various authors have suggested that easy access to vaccines is not sufficient and that it should be combined with other measures such as educational programmes and economic incentives to achieve high vaccination rates31, (32). In our study, we did not focus on assessing the effect of incentives but we did observe that having to pay for vaccines considerably decreased the intention to vaccinate in both groups, particularly in the case of nurses. Some authors have recommended the introduction of health education campaigns especially focused on this professional group33, (34), but several studies suggest that such programmes do not achieve higher rates of vaccine acceptance35–(37).

On the other hand, the intention to vaccinate against A/H1N1 influenza virus among respondents is similar (25.7%) to other studies in Spain38, and is within the wide range reported to date from studies conducted elsewhere9, (20, 26, 39, 40) (11–67%). A greater willingness to vaccinate was also detected among those who had been vaccinated before against seasonal flu, in agreement with what is found in the literature13, (26, 41).

In contrast to findings of other researchers16, we did not find a higher tendency to be vaccinated among those who were properly informed. This might be attributable to the criteria followed for determining whether respondents were ‘properly informed’ and the personal perception of individual health professionals, among other factors.

The main reported arguments against vaccination are the fear of the occurrence of adverse reactions13 and the lack of effectiveness11, (20). In relation to this, several studies have found differences between the two groups surveyed, namely that for nurses the main obstacle to being vaccinated tends to be a fear of adverse reactions13, whereas for doctors it is the lack of effectiveness11, (17).

In our study, most respondents had objections to being vaccinated and did not trust in the effectiveness of the vaccine. This is in agreement with the results obtained with regards to this pandemic in the general population in our geographical area23, (38), but very different from the findings of a study carried out by Lau et al.20, in a different cultural setting, Hong Kong, in which 73% of the respondents from the general population had no objections to being vaccinated.

In our study, the response was stronger among the nurses, who in most cases objected to being vaccinated and believed that there had not been sufficient research on the vaccine. This, together with the fact that many of them questioned the effectiveness of the vaccine, leads us to conclude that, in our sample, the main reasons for not being vaccinated are the perception of lack of safety and of effectiveness of the vaccine, which have also been cited by other researchers11, (13).

According to our results, however, these are not the only factors that can affect the levels of vaccination: specifically, a lower rate of intention to vaccinate was detected among the health personnel who perceived the pandemic as a low-risk situation, in agreement with what has been observed in other studies11, (23, 35). When the data are broken down, we note that again it is the nurses who report the lowest rates of intention to be vaccinated. This is supported by the fact that quite a few of the respondents considered that while they and their families were at risk of being infected, they believed that the mortality associated with the A/H1N1 virus was low.

Despite numerous studies having demonstrated a greater risk of contracting A/H1N1 flu in young people39 and a greater risk of severe symptoms in infants and older individuals40, (41), among the healthcare workers surveyed such findings did not seem to increase perception of risk or translate to a greater intention to vaccinate against the pandemic. Indeed, we observed no significant variations in the opinion of the professionals surveyed by age or by sex, but rather their intentions were affected by personal perception of the risks11, (23, 35) and their confidence in the effectiveness of the vaccine11, (17).

In short, it is essential to determine the barriers to being vaccinated among health professionals, since this low willingness not only has an negative impact on the level of absenteeism, and hence on the healthcare provided16, (29, 31), but also on the rate of transmission of the disease between health professionals and patients,13, (32) and this, without any doubt, is the most important consequence.

Moreover, the effect of the beliefs of health professionals, in particular those of doctors38, on patients regarding certain issues should not be underestimated, as patients who are advised by their doctor to be vaccinated tend to follow this advice. Hence, any measure to improve the level of understanding concerning this and any other pandemic among health professionals translates to a greater awareness among the general population and, correspondingly, a higher rate of vaccination38.

The limitations of the study include the short window of time available for sending and receiving the questionnaires given the imminent start of the vaccination campaign, which led to a low rate of response to the survey. On the other hand, we considered that the most important issue was to avoid the bias of surveying individuals who had already been vaccinated. Another source of bias was selection bias among health professionals who opted to complete the questionnaire; it is plausible that quite a few of them had stronger opinions with respect to this pandemic than their colleagues who did not respond. Taking into account that properly informed health professionals are more likely to be vaccinated, it may be the case that our data are an over-estimation of the intention to vaccinate among health professionals, and that in fact, the rate of vaccination would have been even lower than that predicted by this study.

To conclude, this study focuses on the level of acceptance of the vaccine against A/H1N1 influenza virus among health professionals in our region. Although the results are limited by the low rate of response obtained, they provide information with regards the perception of this pandemic among health professionals that could contribute to the design and implementation of measures to improve strategies used by health organisations, which is of great importance given the high level of rejection of the vaccine, especially among nurses. Such measures should help increase the understanding and acceptance of vaccines among health professionals, which is key for achieving higher rates of vaccination among the general population in this and future pandemics.