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Canadian family physicians' and paediatricians' knowledge, attitudes and practices regarding A(H1N1)… Dubé, Eve; Gilca, Vladimir; Sauvageau, Chantal; Boulianne, Nicole; Boucher, François D.; Bettinger, Julie A.; McNeil, Shelly; Gemmill, Ian; Lavoie, France; Ouakki, Manale 2010

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Dubé et al. BMC Research Notes 2010, 3:102http://www.biomedcentral.com/1756-0500/3/102Open AccessSHORT REPORTShort ReportCanadian family physicians' and paediatricians' knowledge, attitudes and practices regarding A(H1N1) pandemic vaccineEve Dubé*1,2, Vladimir Gilca1,2, Chantal Sauvageau1,2, Nicole Boulianne1,2, François D Boucher1, Julie A Bettinger3, Shelly McNeil4, Ian Gemmill5, France Lavoie1 and Manale Ouakki2AbstractBackground: One of the main determinants of public immunization success is health professionals' support and recommendations. Little is known about the physicians' level of support and intentions regarding A(H1N1) pandemic influenza vaccination. The aim of this survey was to document Canadian family physicians' and paediatricians' knowledge, attitudes and practices (KAP) as well as their intentions regarding A(H1N1) pandemic influenza vaccines right before the beginning of the largest immunization campaign in Canadian history.Findings: A self-administered, anonymous, mail-based questionnaire was sent to a random sample of family physicians and to all paediatricians practicing in Canada. All 921 questionnaires received by October 29 2009 were included in the analysis. Between 72% and 92% of respondents agreed with the statements regarding vaccine safety, effectiveness and acceptability. More than 75% of respondents intended to recommend the A(H1N1) pandemic influenza vaccine to their patients and to get vaccinated themselves. The most significant factors associated with the intention to recommend A(H1N1) pandemic vaccines were physicians' intention to be vaccinated against influenza themselves and the perceived acceptability of the vaccine by the vaccinators.Conclusions: Most Canadian family physicians and paediatricians surveyed were supportive of the A(H1N1) pandemic influenza vaccination before its implementation and large media coverage.FindingsIn June 2009, the World Health Organization declared aninfluenza A(H1N1) pandemic[1]. Modelling studies haveshown that vaccination is the most effective interventionin reducing A(H1N1) pandemic influenza morbidity, hos-pitalisation, and mortality [2-4]. It is commonly recog-nized that the results of an immunization campaign aredetermined by vaccine characteristics, vaccination cam-paign timelines and vaccine uptake. However, the successof a new vaccination campaign should not be taken forgranted and public acceptance of a new vaccine shouldnot be assumed [5-7]. Health professionals are known tobe the most trusted source of information about vaccina-tion in Canada [8] and their recommendation is one ofthe main determinants of vaccine uptake [9-11]. Bothfamily physicians and paediatricians are involved in rou-tine vaccine delivery and are expected to play a major rolein emerging pandemic vaccination campaigns. However,very little data exist about their acceptance of a pandemicvaccine and, to our knowledge, no systematically col-lected data regarding physician knowledge, attitudes andpractice (KAP) on A(H1N1) pandemic vaccine have beenreported.The main aim of this paper is to document Canadianfamily physicians' and paediatricians' KAP regardingA(H1N1) pandemic influenza and its prevention by vac-cination prior to vaccine approval for clinical use andlarge media coverage of the immunization campaign.MethodsA self-administered, anonymous, mail-based question-naire was sent between August 20 and September 30* Correspondence: eve.dube@ssss.gouv.qc.ca1BioMed Central© 2010 Dubé et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.2009 to a random sample of 1182 family physicians and to Centre de recherche du CHUL-CHUQ, Centre Hospitalier de l'Université Laval, Québec, CanadaFull list of author information is available at the end of the articleDubé et al. BMC Research Notes 2010, 3:102http://www.biomedcentral.com/1756-0500/3/102Page 2 of 5all 1852 Canadian paediatricians. The Canadian MedicalDirectory [12] was used to identify paediatricians and toobtain a random sample of family physicians. This data-base contains more than 58 000 listings of medical con-tact information and is updated each year. Based on theanalytical framework for immunization programs in Can-ada [13], the first section of the questionnaire addressedthe respondents' KAP regarding routinely used and newlytion or the vaccine was provided. Descriptive statisticswere generated for all variables. Multivariate logisticregressions models were used to determine variables inde-pendently associated with the intention to recommend theA(H1N1) pandemic vaccine. Dependent variables weredichotomized: the responses "strongly agree" and "agree"versus all others. Missing responses were excluded fromthe analysis. Variables associated in the univariate analysisTable 1: Knowledge, attitudes and practices regarding A(H1N1) pandemic influenza and A(H1N1) pandemic influenza vaccineStrongly Disagree/DisagreeSomewhat Disagree Somewhat Agree Agree/Strongly AgreeFamily Physicans (n = 207)*A(H1N1) pandemic influenza ...Is a serious disease 4% 10% 32% 49%Would occur frequently in Canada without vaccination8% 10% 26% 52%Generate a significant economic burden in Canada4% 5% 17% 69%A(H1N1) pandemic influenza vaccine will be...Safe 5% 10% 35% 38%Effective 4% 9% 46% 26%Well accepted by the public 6% 17% 35% 38%Well accepted by vaccinators 3% 8% 26% 58%I will recommend A(H1N1) pandemic vaccine to my patients1% 6% 20% 68%Paediatricians (n = 714)*A(H1N1) pandemic influenza ...Is a serious disease 3% 6% 27% 59%Would occur frequently in Canada without vaccination6% 6% 24% 59%Generate a significant economic burden in Canada2% 3% 15% 77%A(H1N1) pandemic influenza vaccine will be...Safe 2% 6% 36% 43%Effective 3% 6% 45% 28%Well accepted by the public 5% 13% 34% 42%Well accepted by vaccinators 2% 4% 21% 67%I will recommend A(H1N1) pandemic vaccine to my patients2% 3% 15% 75%*Due to missing responses, row percentages may not add up to 100%.available or candidate vaccines in Canada, including theA(H1N1) pandemic vaccine. Respondents were asked tobase their answers on their own knowledge and opinion.No information on A(H1N1) pandemic influenza infec-with the intention to recommend the vaccine at p ≤ 0.20were entered into the multivariate regression models usingthe stepwise selection technique. Variables were reevalu-ated in the final model to check for confounding andDubé et al. BMC Research Notes 2010, 3:102http://www.biomedcentral.com/1756-0500/3/102Page 3 of 5model fit. A probability level of p < 0.05 based on two-sided tests was considered statistically significant. The col-linearity was checked and the adequacy of the model wasevaluated by Hosmer and Lemeshow's goodness of fit test.The Statistical Analysis Systems (SAS) software (version9.1) was used for statistical analysis. The study protocolwas approved by the Ethics Board of the Laval UniversityHospital Center (reference number 126.05.02).The A(H1N1) pandemic vaccine was approved in Can-ada at the end of October 2009. Due to important educa-tional efforts undertaken afterwards and their potentialimpact on physicians' KAB, we have decided to performtwo separate analyses. Only questionnaires receivedbefore October 29 2009 were included in this analysis.ParticipationThis study is ongoing. All 921 questionnaires received byOctober 29 2009, after the first questionnaire mailing,were included in this report. After exclusion of 208 physi-cians no longer practicing or with wrong addresses, theoverall participation rate was 31% (18% for family physi-cians and 39% for paediatricians). Of the 207 family phy-sicians who managed to complete the survey by October29 2009, 64% spent more than 21 hours a week in outpa-tient consultation, 51% were men and 58% had been prac-ticing medicine for 20 years or longer. Of the 714paediatricians who managed to complete the survey byOctober 29 2009, 52% spent more than 21 hours a weekin outpatient consultation, 42% were men and 46% hadbeen practicing for 20 years or longer. Eighty seven per-cent of family physicians and 59% of paediatricians statedthat vaccines were administered at their main practice.Knowledge, attitudes and practices regarding A(H1N1) pandemic influenza and its prevention by vaccinationOne third of family physicians (33%) and almost half ofthe paediatricians (46%) had had experience withA(H1N1) pandemic influenza disease before respondingto this survey. Overall, 82% of family physicians and 88%of paediatricians estimated that "A(H1N1) pandemicinfluenza is severe enough to take special precautions toprevent it".Approximately 80% of both family physicians and paedi-atricians perceived A(H1N1) pandemic infection as a seri-ous disease, that would occur frequently withoutvaccination (Table 1). Thirty seven percent of family physi-cians and 45% of paediatricians strongly agreed thatA(H1N1) generates a significant economic burden in Can-ada. From 72% to 79% of respondents agreed with thestatements regarding the usefulness and safety of theA(H1N1) pandemic influenza vaccines. Comparatively,52% of family physicians and 72% of paediatricians agreedor strongly agreed that seasonal influenza vaccines are veryuseful to protect children's health. More than 70% of familyphysicians and paediatricians considered that theA(H1N1) pandemic vaccine would be well accepted by thepublic and more than 80% that it would be well accepted bythe vaccinators. The majority of family physicians (88%)and paediatricians (90%) intended to recommend theA(H1N1) pandemic influenza vaccine to their patients:30% of family physicians and 43% of paediatricians statedthat they would strongly recommend it. When recom-mending new vaccines, 38% of family physicians and 54%of pediatricians stated being highly influenced by recom-mendations made by professionals associations. Seventy-seven percent (77%) of family physicians and 83% of paedi-atricians intended to get vaccinated against A(H1N1) pan-demic influenza themselves while 15% of family physiciansand 13% of paediatricians were undecided.Finally, 47% of family physicians and 36% of paediatri-cians considered that their knowledge on the A(H1N1)pandemic influenza vaccine was insufficient, while 28%of family physicians and 30% of paediatricians consideredit to be somewhat sufficient.Table 2: Variables associated with respondents intention to recommend A(H1N1) pandemic vaccine*Variables OR 95% CI P valueRespondents intention to receive A(H1N1) pandemic vaccine 7.81 4.32-14.14 <0.0001Belief§ that A(H1N1) pandemic vaccine will be well accepted by vaccinators 6.41 3.89-10.58 <0.0001Belief§ that A(H1N1) pandemic influenza generate a significant economic burden in Canada3.28 1.92-5.61 <0.0001Being influenced by recommendations made by professionals associations when recommending new vaccines2.32 1.15-4.68 0.02Belief§ that A(H1N1) pandemic influenza vaccine will be safe 2.30 1.33-3.98 0.003Belief§ that A(H1N1) pandemic influenza is a serious disease 2.12 1.25-3.57 0.005Belief§ that seasonal influenza vaccines are very useful to protect children health 2.01 1.21-3.34 0.007* Multivariate analyses; OR = odds ratio; CI = confidence interval§ Strongly agree, agree, somewhat agreeDubé et al. BMC Research Notes 2010, 3:102http://www.biomedcentral.com/1756-0500/3/102Page 4 of 5Factors associated with intention to recommend A(H1N1) pandemic vaccinesIn multivariate analyses, the most significant factors asso-ciated with respondents' intention to recommend theA(H1N1) pandemic vaccine were: intention to get vacci-nated against A(H1N1) pandemic influenza themselves;belief that A(H1N1) pandemic vaccine would be wellaccepted by the vaccinators; perceived safety of theA(H1N1) pandemic vaccine; belief that A(H1N1) pan-demic influenza generates a significant health and eco-nomic burden; perceived usefulness of seasonal influenzavaccination and compliance with professional associa-tions' recommendations when recommending new vac-cines (Table 2).InterpretationThis survey was conducted at a time when relatively littleinformation about the characteristics of the second waveof A(H1N1) pandemic influenza was available and whenvery limited data about the new A(H1N1) pandemic vac-cines' immunogenicity and safety was disclosed. How-ever, more than one out of three respondents had hadsome experience with cases of A(H1N1) pandemic influ-enza and the majority of them were willing to recom-mend the A(H1N1) pandemic vaccine to their patients.More than 75% of the respondents also indicated a will-ingness to get the vaccine themselves. This proportion ishigh when compared to the 26% to 61% vaccination cov-erage rates for seasonal influenza among healthcareworkers reported in a recent Canadian study [14].Few studies have been done to assess healthcare profes-sionals' KAP regarding pandemic influenza and its pre-vention by immunization [15-17]. Results of anAustralian survey conducted in 2007 with a conveniencesample of clinical and non-clinical healthcare workersindicated that 86.8% of medical staff respondents consid-ered that a pandemic influenza would be "very serious" ifone was to occur. The majority of healthcare workers sur-veyed in 2007 (77.5%) believed that the vaccine wouldprotect them against pandemic influenza [16]. Results ofanother survey conducted in May 2009 with 389 hospitalhealthcare workers (mainly nurses) in Hong Kong indi-cated that 47.9% of them intended to accept A(H1N1)pandemic vaccination [15].One internet survey done in April-May 2009 in Canadareported that 32% of the 213 general practitioners sur-veyed considered A(H1N1) infection to be a serious orextremely serious disease [17]. Four months later, 49% offamily physicians and 59% of paediatricians who partici-pated in our survey agreed or strongly agreed that theA(H1N1) pandemic infection was a serious disease (addi-received and by policy development regarding A(H1N1)influenza prevention over the summer of 2009.It is of note that physicians' intention to get the vaccinefor themselves and the perceived acceptability of theA(H1N1) pandemic vaccine by the vaccinators are thefactors the most strongly associated with the intention torecommend the vaccine to their patients. Several studieshave shown that the support of an immunization strategyby vaccinators is perceived as a crucial element in healthprofessionals' intention to adhere to it [13,18,19].Beliefs that A(H1N1) pandemic influenza generates asignificant economic burden, beliefs that A(H1N1) pan-demic influenza is a serious disease, as well as beliefs inthe safety of the A(H1N1) pandemic vaccine, were associ-ated with physicians' intention to recommend theA(H1N1) pandemic vaccine. However, this associationwas unexpectedly lower when compared to the perceivedacceptability of vaccine by vaccinators and personalintention to be vaccinated. Finally, the influence of rec-ommendations made by professional associations on phy-sicians' intention to recommend a new vaccine isconsistent with results of previous studies [20-22].This study has several limitations. First, as in mosthealth professionals' surveys, there is a potential for nonparticipation bias and socially desirable responses. Theanalysis was limited to the time period before theapproval of A(H1N1) pandemic vaccines in Canada andonly responses received by October 29 2009 wereincluded. Participation rate for this time period was rela-tively low. However, respondents' demographics and pro-fessional characteristics were similar to recent studieswith higher response rates conducted in Canadian familyphysicians and paediatricians [23-25]. The fact that thequestionnaire was anonymous should also diminishsocially desirable responses. Second, this study was con-ducted before the federal government announced theapproval of the A(H1N1) pandemic influenza vaccine andattitudes may have changed after that, as demonstrated ina recent UK study [26]. In the latest study in healthcareworkers, more respondents indicated willingness toaccept stockpiled H5N1 vaccine during a period of highmedia coverage due to an H5N1 outbreak at a commer-cial poultry farm than after (63.4%, vs. 51.9%; p = 0.009)[26]. In our survey, between 12% and 15% of respondentsdid not answer to statements regarding A(H1N1) pan-demic influenza vaccine safety and efficacy. This highlevel of missing responses, as well as the high proportionof relatively neutral answers, is due in our opinion to therespondents' perceived lack of information on theseissues. Finally, the question regarding respondents' inten-tion to recommend A(H1N1) pandemic vaccine did nottional 27% to 32% somewhat agreed). Changes in healthprofessionals' perceived seriousness of a pandemic dis-ease might be explained by additional informationspecify the patients' age groups (children versus adults).In our opinion, this could explain, at least partially, somedifferences observed between family physicians' and pae-Dubé et al. BMC Research Notes 2010, 3:102http://www.biomedcentral.com/1756-0500/3/102Page 5 of 5diatricians' intentions to recommend A(H1N1) pandemicvaccine.In summary, most Canadian family physicians and pae-diatricians surveyed were supportive of A(H1N1) pan-demic influenza vaccination before its implementationand large media coverage. The next phase of the surveywas launched one month after the implementation ofA(H1N1) pandemic influenza vaccination in Canada.Results of this first phase provide baseline data to serve ascomparison for data collected during the vaccinationcampaign. Analysis of the responses received after Octo-ber 29 2009 will give us the opportunity to explore theeffect of A(H1N1) pandemic vaccine approval as well asadditional dissemination of information, including pro-fessional associations' recommendations, on physicians'KAP regarding pandemic influenza and its prevention byvaccination.Competing interestsThis study was financially supported by the Quebec Ministry of Health andSocial Services and an unrestricted grant from GlaxoSmithKline. No privatecompany or their employees were involved in study protocol/questionnairedesigning, data collection or data analysis and interpretation.Authors' contributionsAll authors have been involved in the design of the study. ED, VG and CS havedrafted the manuscript. MO performed the statistical analysis. All authors haveread and approved the final version of the manuscript.AcknowledgementsWe thank the Canadian Association for Immunization Research and Evaluation (CAIRE) and the Canadian Paediatric Society for their collaboration in this study.Author Details1Centre de recherche du CHUL-CHUQ, Centre Hospitalier de l'Université Laval, Québec, Canada, 2Institut National de Santé publique du Québec, Québec, Canada, 3University of British Columbia, Vaccine Evaluation Center, BC Children's Hospital, Vancouver, British Columbia, Canada, 4Canadian Center for Vaccinology, Halifax, Nova Scotia, Canada and 5Kingston, Frontenac and Lennox & Addington Public health Unit, Kingston, Ontario, CanadaReferences1. Chan M: World now at the start of 2009 influenza pandemic.  2009 [http://www.who.int/mediacentre/news/statements/2009/h1n1_pandemic_phase6_20090611/en/index.html]. 2009-06-11 [cited 2009-10-26]2. 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Vaccine 2009, 27(2009):1242-1247.doi: 10.1186/1756-0500-3-102Cite this article as: Dubé et al., Canadian family physicians' and paediatri-cians' knowledge, attitudes and practices regarding A(H1N1) pandemic vac-cine BMC Research Notes 2010, 3:102Received: 9 December 2009 Accepted: 14 April 2010 Published: 14 April 2010This article is available from: http://www.biomedcentral.com/1756-0500/3/102© 2010 Dubé et a ; lic nsee BioMed Central Ltd. is an Open Access article distributed under th  terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.BMC Research Notes 2010, 3 1026. Lau JTF, Yeung NCY, Choi KC, Cheng MYM, Tsui HY, Griffiths S: Acceptability of A/H1N1 vaccination during pandemic phase of influenza A/H1N1 in Hong Kong: population based cross sectional survey.  BMJ 2009, 2009(339):b4164.

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