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Infants and Children

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Immunisation attitudes, knowledge and practices of health professionals in regional NSW Abstract

Julie Leask

Objective: This study investigated the immunisation knowledge, attitudes and practices among health professionals in two regional Area Health Services of NSW with low and high immunisation rates. It also compared these factors between the areas and between the health professional groups. Methods: A self-administered

National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases (NCIRS), The Children’s Hospital at Westmead and the Discipline of Paediatrics and Child Health, University of Sydney, New South Wales

Helen E. Quinn National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases (NCIRS), The Children’s Hospital at Westmead and the University of Sydney, New South Wales

questionnaire was posted in 2006 to health professionals, located within the North Coast and Hunter New England Area Health Services, whose practice could include immunisation. This included general practitioners (GPs), practice nurses, community nurses, hospital nurses and midwives. Results: Out of 926 surveys sent, 434

Kristine Macartney National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases (NCIRS), Department of Infectious Diseases and Microbiology, The Children’s Hospital at Westmead and the University of Sydney, New South Wales

Marianne Trent North Coast Population Health, New South Wales

were returned (47%). The great majority of the health professionals (97%) believed that vaccines were safe, effective and necessary. However, in approximately onethird of respondents, there were specific concerns about additives, immune system overload and the number of vaccines.

Peter Massey and Chris Carr Hunter New England Population Health, New South Wales

John Turahui North Coast Population Health, New South Wales

Significantly more health professionals in the North Coast area believed that additives in vaccines may be harmful and that adding more vaccines to the schedule would make immunisation too complex. Among GPs, over half felt uncomfortable about giving more than two injections at the one visit. Conclusions: Health professionals in this study had overall confidence in vaccines but had specific concerns about the number of vaccines given to children and vaccine content. These unfounded concerns may reduce parental confidence in immunisation. Implications: There is value in governments and immunisation support workers continuing their efforts to maintain up-to-date knowledge among health professionals and support the delivery of appropriate and targeted information to address concerns about vaccines. Keywords: Health Care Surveys;

A

ustralia currently enjoys high immunisation rates with 94% of 2-year-old being fully vaccinated.1 Most vaccines for children are publicly funded and provided free at point of care under the National Immunisation Program (NIP), and vaccine coverage is recorded and reported by the national populationbased Australian Childhood Immunisation Register (ACIR). Despite high vaccination rates, pockets of opposition to vaccination exist in some communities in Australia, where lower coverage rates are known to occur. Communities with low vaccination coverage experience outbreaks of vaccinepreventable diseases.2 Concerns about vaccine safety significantly

contribute to under-immunisation of children. A 2001 Australian study found that 58% of parents of children not up-todate for immunisation cited disagreement or concerns about immunisation as their main reason.3 For advice regarding the safety of vaccines, parents look foremost to health professionals.4-6 Therefore, it is essential that health professionals are equipped to respond confidently to a wide range of parental concerns. Instances where health professional confidence in immunisation safety has declined have been followed by major reductions in immunisation rates.7 Few studies have compared attitudes between health professionals in areas of low and high immunisation rates. This study

Health Knowledge, Attitudes, Practice; Vaccination; Australia; Health Personnel; Measles-Mumps-Rubella Vaccine Aust N Z Public Health. 2008; 32:224-9

Submitted: September 2007

Revision requested: January 2008

Accepted: March 2008

Correspondence to: J. Leask, NCIRS, The Children’s Hospital at Westmead, University of Sydney, Locked Bag 4001, Westmead NSW 2145, Australia. Fax: (02) 9845 1418; e-mail: [email protected]

doi: 10.1111/j.1753-6405.2008.00220.x

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AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH © 2008 The Authors. Journal Compilation © 2008 Public Health Association of Australia

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aimed to describe differences in attitudes between two regional areas in New South Wales (NSW) where, in 2005, immunisation coverage rates by two years of age differed at 86% for the North Coast (NC) and 93% for the Hunter New England (HNE). 8 The second aim of the study was to identify the immunisation knowledge, attitudes and practices among health professionals who provide immunisation in regional NSW, with a focus on differences between professional groups. The goal was to improve the existing support of health professionals and ultimately to find targeted ways to improve immunisation rates, particularly in areas with sub-optimal coverage. A particular focus of this study was to examine beliefs about the safety of the MMR vaccine in the light of an alleged but unfounded link to inflammatory bowel disease and autism, and evidence of the impact of this concern on UK health professionals.9,10 In addition, we examined the impact that the changes to the immunisation schedule prior to the survey had had on health professionals. This included the introduction of new vaccines and many schedule changes. Meningococcal C and pneumococcal conjugate vaccines and varicella zoster vaccines were recommended as part of the schedule but, for a time, not funded under the NIP.11 A funded program for hepatitis B vaccination of all neonates, rather than just those at risk, also commenced. With this change, midwives became the first provider of immunisation to infants. As a relatively new immunisation provider in Australia, our study sought information on the extent of midwives’ concerns about vaccine safety.

Methods Data collection The study was an anonymous self-completed postal survey of immunisation health professionals from the Hunter New England and North Coast Area Health Services (AHS) in NSW. The target population for the survey was health care providers involved in immunisation. This included general practitioners (GP), practice nurses (PN), early childhood nurses, generalist community nurses, midwives, and hospital nurses from paediatrics wards, neonatal intensive care and emergency departments. Approval was gained from the Hunter, New England, and the North Coast Area Research Ethics Committees.

Survey development A range of data informed development of the survey including the findings of previous studies and the in-depth knowledge of local immunisation coordinators (MT, CC, JT, PM).10,12-14 Many of the questions were adapted from a 2002 unpublished survey of health care workers in Western Sydney, NSW and a 1998 survey of health professionals in Quebec, Canada.15,16 The survey was pre-tested with a sub-sample of 11 health professionals from each AHS. The survey covered five major areas: 1. Knowledge regarding vaccine contraindications. 2. Beliefs and attitudes about safety and necessity of certain vaccines. 3. Practices in recommending unfunded vaccines. 2008 vol. 32 no. 3

4. 5.

Practices in communicating with parents about immunisation. Resources currently utilised.

Sampling procedure Previous research in Western Sydney indicated that, in an area of high vaccine coverage, such as the Hunter New England, 95% of health professionals would be supportive of immunisation.15 We assessed that if only 88% of health professionals in the North Coast were to support immunisation, this 7% difference may influence coverage. To detect this difference with 80% power at a significance level of 0.05, 248 health professionals were required from each area. The sampling procedure involved stratifying by each AHS and sampling each health professional group proportionally to the population distribution of all health professionals within that area. The exception to this was midwives, who were ‘over sampled’ in each area to allow precise estimates for this group alone. After taking into account likely response rates, 507 health professionals from the NC and 419 health professionals from HNE were mailed the questionnaire. For each health professional group, participants were randomly selected from records kept by public health units. Surveys were sent in April 2006 with a follow-up mailout to non-respondents.

Data analysis Completed questionnaires were reviewed and information entered into an EpiInfo database. Data cleaning, recoding and statistical analysis were performed using SAS v9.1.3. Samples were weighted to take into account non-response and disproportionate sampling of health professionals from each AHS. Where possible, response variables, including 5 point Likert scales for agreement, were collapsed into dichotomous variables. Unless otherwise stated, those reporting ‘agree strongly’ or ‘agree somewhat’ were recoded as ‘agree’ and compared with all others (including ‘disagree strongly’, ‘disagree somewhat’ and ‘unsure’). Where results for early childhood nurses and generalist community nurses were combined a new group was named ‘Community Nurses’. Point estimates and 95% confidence intervals (CI) were calculated where appropriate. When comparing the two areas, point estimates and confidence intervals were used to determine signif icance. Non-overlapping conf idence intervals were considered significant. When comparing dichotomous variables, an odds ratio was calculated and a chi square test used to assess statistical significance. A p value less than 0.05 was considered statistically significant. Content analysis was performed on text responses and included grouping answers into common themes.

Results Of 926 surveys sent, 427 were returned completed (47%). Response rates to the survey varied between the AHS and health professionals (Table 1). In comparison with population data on GPs, our survey over-represented females (43% this study versus 33% NSW medical workforce census data).17


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Immunisation attitudes Childhood vaccines in the National Immunisation Program at the time of the survey were considered to be safe by 414 of the 427 respondents (97%), effective by 416 (98%) and necessary by 409 (96%). No significant difference was found between HNE and NC areas. Table 2 shows these findings by professional group. Respondents rated their level of agreement with a number of commonly held concerns about vaccines (Figure 1). Significant proportions agreed that children get too many vaccines in the first two years of life. Consistently more health professionals in the NC area compared with HNE agreed with these statements of concern; however, these differences were only statistically significant regarding the statement that additives in vaccines may be harmful (23%, [95% CI: 16.9-28.7%] versus 10%, [95% CI: 6.3-14.0%]). When examining these results by health professional category, hospital nurses were more likely to agree or be unsure about all the statements than those in general practice. In addition, midwives were significantly more likely than all other respondents to agree that the additives in vaccines may be harmful (53% versus 36% [OR: 2.0, 95% CI: 1.3-3.0]) and that concurrent immunisation might overload the immune system (56% versus 28% [OR: 3.3, 95% CI 2.1-5.1]. Respondents were asked about the importance of vaccinating Figure 1: Proportion of NSW regional health professionals who agree with, are unsure about, or disagree with specific statements about vaccination. Additives in vaccines may be harmful

Concurrent immunisation might overload immune system Agree

Children get too many vaccines in the first two years of life

Unsure Disagree

Good eating habits/healthy lifestyle reduce need for immunisation Complementary health practices reduce need for immunisation 0%

Area response rates Hunter New England North Coast

Health professional group response rates General Practitioner 95 Practice Nurse 81 Early Childhood Nurses 30 Generalist Community Nurses 40 Hospital Nurses 76 Midwives 112

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With regard to true and false contraindications to vaccination, based on the NHMRC Australian Immunisation Handbook 8th edition, the majority of GPs and PNs correctly believed that vaccines could still be given with antibiotic use (86%); temperature of 37°C and runny nose (90%); family history of convulsions (87%); and child’s mother being pregnant (89%); and should not be given when the child had a temperature of 38°C and felt unwell (95%). There were no significant differences in these results between areas. Table 3 shows beliefs about an association between MMR vaccine, inflammatory bowel disease and autism. Only 59% of respondents believed there was no association, with little difference between the two areas. Overall, hospital nurses and midwives had

Complete Surveys sent Rate % 221 213

Immunisation knowledge and beliefs

Table 2: Proportions of health professionals in regional NSW agreeing that childhood vaccines are safe, effective and necessary.

20% 40% 60% 80% 100%

Table 1: Survey response rates by area and health professional category.

young children against specific diseases. Vaccination against polio was most strongly supported (95% agreed completely) followed by pertussis (94%), measles (92%), pneumococcal disease (85%), hepatitis B (84%), meningococcal type C disease (80%), and varicella (79%). When examining the attitudes of specific health professionals, both early childhood nurses and practice nurses were significantly more likely than GPs to agree completely about the importance of vaccinating young children against varicella (early childhood nurses 94% versus GPs 73% [OR: 5.7, 95% CI: 1.2-26.1] and practice nurses 89% versus GPs 73% [OR: 3.0, 95% CI: 1.4-6.6]). Similarly, practice nurses were significantly more likely than GPs to agree completely about the importance of vaccinating young children against meningococcal C (PNs 98% versus GPs 77% [OR: 2.4, 95% CI: 1.1-5.3]) and hepatitis B (PNs 92% versus GPs 80% [OR: 3.0, 95% CI: 1.2-7.4]). There was general support for the neonatal hepatitis B vaccine for newborns with overall 83% agreeing it was necessary and 85% agreeing it was safe. While 88% of midwives felt the vaccine was necessary, slightly fewer (81%) believed it was safe and 35% felt it was given too young. GPs had the least support for the vaccine, with only 77% believing the newborn dose to be necessary for disease control.

419 507

53 42

260 136 45 69 141 275

37 60 67 58 54 41

Health professionalb

%a

Safe Effective Necessary

Practice Nurse n=81 100 General Practitioner n=95 100 Hospital Nurses n=74 97 Generalist Community Nurses n=39 96 Early Childhood Nurses n=30 94 Midwives n=109 92

100 97 92 96 91 98

97 97 97 96 98 93

OVERALL

98

96

97

Notes: (a) Weighted percentages (b) Total for each group vary due to missing data


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the most uncertainty with 57% and 40% respectively, being unsure. Community nurses were the group most likely to believe in an association with 21% responding “yes”. Of all respondents, only 7% correctly answered that there was an association between MMR vaccine and a rare bleeding disorder, thombocytopenic purpura, despite the established link being listed in the Australian Immunisation Handbook 8th edition.11

During the time that certain vaccines were recommended as part of the Australian Standard Vaccination Schedule but were not publicly funded under the National Immunisation Program, only around half of all GPs would “mostly or always” recommend them (meningococcal C vaccine [57%], pneumococcal vaccine [46%], and varicella vaccine [47%]).

Use of resources Responding to concerned parents and conscientious objectors Respondents were given a list of all current vaccines on the schedule and asked which ones raised the most questions and concerns from parents and what these concerns were. Of the eight vaccines listed (Table 4), respondents noted the MMR vaccine as most frequently raised by parents, with the majority of concerns about a link to autism. For hepatitis B vaccine, the most commonly reported questions were about necessity and the view that the vaccine was given “too young”. The question of vaccine necessity was the most commonly reported issue regarding varicella, pneumococcal and polio vaccines. In their discussions with parents, most respondents felt confident answering questions about immunisation. Community nurses reported significantly more confidence (99%) than hospital nurses and midwives combined (77%) [OR: 23.0, 95% CI 3.6146.7]. GPs and PNs combined also reported significantly more confidence than hospital nurses and midwives combined (91%) [OR: 3.2, 95% CI 1.7-5.8]. When parents refused immunisation for their child, only 2% of GPs would refuse to treat the child in the future and 18% would never sign the form required by vaccination conscientious objectors to receive government family assistance payments.

The vaccine schedule One-third of all respondents felt that adding more vaccines to the schedule would make immunisation too complex for health professionals. This was reported significantly less often in HNE (28%, 95% CI: 22-34%) when compared with NC (43%, 95% CI: 36-50%). GPs and PNs were asked about their practices and feelings about giving more than two injections at the one visit. The majority said they would give more than two injections if needed (89% for GPs and 91% for PNs), but almost half (46%) of all GPs and one-third (35%) of PNs reported feeling uncomfortable doing so.

The utilisation of immunisation resources is shown in Figure 2. The Australian Immunisation Handbook 8th edition in hardcopy was rated as useful by 93% of health professionals, while the accompanying CD and online version were less often reported as useful. The second most useful resource was a booklet for consumers, Understanding Childhood Immunisation and telephone advice from the public health unit (PHU), whereas websites were the least used resource. When examining the popularity of resources by health professional group, 94% of GPs and 95% of PNs found newsletters from Divisions of General Practice (DGP) a useful source of information on immunisation. Between 86% and 100% of community nurses found the local immunisation coordinator, PHU telephone advice, and the Understanding Childhood Immunisation booklet useful.

Continuing education The highest rate of accreditation training occurred among community nurses, with 93% reporting having undergone or undergoing the immunisation accreditation course. This was followed by practice nurses (69%), midwives (39%) and hospital nurses (26%). Nurses who received accreditation training Table 4: Specific vaccine concerns or questions raised by parents according to NSW regional health professionals. Childhood vaccine raised by parent

Number of respondents nominating concerns about vaccine raised by parents

MMR Hepatitis B Varicella Meningococcal C DTPa Pneumococcal conjugate Polio Hib

174 133 94 73 52 33 21 10

Table 3: Beliefs about MMR vaccine among NSW regional health professionals. Beliefs about an association between MMR vaccine and each condition

yes unsure no

%a

Inflammatory Autism bowel disease 17 37 59

12 29 59

Idiopathic thrombocytopenic purpura 7 45 48

Note: (a) Weighted percentages

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reported significantly more confidence in answering parental questions about immunisation (p