Childhood Vaccinations: Knowledge, Attitudes and Practices of Paediatricians and Factors Associated with Their Confidence in Addressing Parental Concerns, Italy, 2016

"The interaction between paediatricians and parents is important in building and maintaining confidence in the vaccination programme and maintaining high levels of vaccination uptake, and paediatricians should be more proactive in initiating the conversation about vaccines with parents rather than waiting for them to raise specific questions or concerns."

Given the critical role that paediatricians play in providing information to parents about childhood vaccinations, these researchers performed a study to examine vaccination knowledge, attitudes, and practices among paediatricians in Italy, and to identify factors associated with their feeling sufficiently knowledgeable about vaccinations and vaccine-preventable diseases (VPDs) to be able to confidently address parental questions. The survey was part of a wider project funded by the Ministry of Health, aiming to describe vaccine refusal in Italy and to prepare ad hoc communication tools. It was conducted before the introduction in Italy of a law extending the number of mandatory vaccinations from 4 (poliomyelitis, tetanus, diphtheria and hepatitis B) to 10 (pertussis, Haemophilus influenza type b vaccine, measles-mumps-rubella (MMR) and varicella, in addition to the 4 already mandatory) in children up to 16 years of age.

Vaccine hesitancy is defined by the Strategic Advisory Group of Experts on Immunization (SAGE) as a "delay in acceptance or refusal of vaccines despite availability of vaccination services". The researchers observe that healthcare workers (HCWs), including paediatricians, may themselves have concerns regarding the usefulness of vaccines and vaccine side effects and be vaccine-hesitant regarding vaccinations for themselves, their children, or their patients. Their beliefs and attitudes may lead them to recommend vaccines to their patients less frequently and may have a negative influence on parents' vaccination acceptance.

To assess the situation, the researchers developed a self-completed electronic survey on the SurveyMonkey internet platform and conducted it from February to March 2016 among Italian paediatric specialists registered with any of the 5 main scientific paediatric societies in Italy.

Two-thirds of paediatricians (570/862) felt sufficiently knowledgeable about vaccinations and VPDs to be able to confidently discuss them with parents. The 5 main topics for which paediatricians who do not feel knowledgeable about vaccinations would like to obtain additional training in were: safety of vaccines (priority score: 5.25), how to respond to parental concerns (4.97), VPD epidemiology and complications (4.84), vaccine contraindications (4.74) and vaccine efficacy (4.70). When asked to indicate how much each of 6 possible training tools/settings influenced their knowledge of vaccines and VPDs, 30% (252/854) reported they had received either very little or no formal training in vaccinology during their university studies. Participation in immunisation conferences and courses played an important role for most paediatricians.

Most paediatricians considered vaccines to be effective or very effective, with a range from 83.5% (738/884) for the human papillomavirus (HPV) vaccine to 99.6% (887/891) for the diphtheria-tetanus-acellular pertussis vaccine. In general, 95.3% (843/885) of paediatricians reported being completely favourable to vaccinations, 3.8% (34/885) were moderately favourable, 0.8% (7/885) had a neutral attitude, and 1 paediatrician (0.1%) was completely against vaccinations. Fifty-eight percent (512/883) reported being favourable to schools requiring pupils to be vaccinated.

When asked to rate their level of agreement with 19 statements about vaccine safety and effectiveness, only 8.9% (80/903) of paediatricians fully responded in that way. (The researchers say they expected them to be in complete disagreement with vaccine-critical statements and in complete agreement with positive statements.) Most paediatricians (837/899; 93.1%) perceived that, in the previous 2 years, parents had become increasingly worried about vaccinations. Vaccine safety concerns were perceived by most paediatricians (595/899; 66.2%) as the single most important reason for which parents refuse to vaccinate their child.

Ninety-nine per cent of paediatricians (891/900) recommend that parents follow the national immunisation schedule, 0.3% (3/900) recommend only compulsory vaccinations, and 0.2% (2/900) recommend parents not to vaccinate against any VPD. Four paediatricians (0.5%) responded they have a neutral attitude and do not express their opinion regarding vaccinations to parents.

Overall, 89.9% (808/899) reported frequently discussing with parents about the importance of vaccination, 7.8% (70/899) did so occasionally, 1.9% (17/899) only if parents brought up the topic, and 0.4% (4/899) never. When faced with parents who refuse to vaccinate their child against one or more diseases, 97.8% (861/880) of paediatricians stated they try to change parents' minds by providing information about vaccines and risks of diseases. When faced with parents who want to delay vaccinations, only 90.1% (790/877) of paediatricians stated they try to change their minds.

Most paediatricians (651/901; 72.3%) reported having implemented vaccination promotion activities in the previous year, including putting posters and information materials in their waiting rooms (491/901; 54.5%), sending reminders by post or phone (50/901; 5.6%), organising meetings with parents or groups of parents (110/901; 12.2%), sending or giving written information materials to parents (39/901; 4.3%), and recommending websites with reliable vaccine information.

In reflecting on the findings, the researchers note that, although most paediatricians were favourable to vaccinations in general, a considerable proportion (one-third) of the sample did not feel sufficiently informed about vaccines and VPDs and about how to address parental concerns. Some paediatricians were found to have a falsely low perception of disease risk. In addition, a relevant number held false beliefs about vaccines and expressed concerns about the safety or usefulness of vaccines. About one-third reported they did not completely trust vaccine information given by health authorities and scientific societies. These results add to similar studies conducted among healthcare workers in Europe indicating that vaccine hesitancy exists not only in the general population but also, to some extent, in HCWs.

The study identified some knowledge gaps regarding true and false contraindications to vaccinations, which could impede paediatricians in being able to confidently reply to parents' questions and avoid missing opportunities to administer recommended vaccines in a timely manner. "Vaccinology courses, including courses in communication, should be part of the university core curriculum for all future health professionals and of compulsory continuing medical education requirements for health professionals involved in vaccinations." In a 2016 review of studies on vaccine hesitancy among healthcare providers, knowledge about vaccines and vaccine efficacy and safety was found to contribute to providers' confidence and increase their willingness to recommend vaccination.

The researchers conclude that, "To maintain high levels of vaccination uptake, paediatricians must be familiar with risks of VPD, vaccine safety, and false contraindications, dispel any doubts they themselves may have regarding false myths and be able to effectively communicate information about vaccines to parents....There is also a need to strengthen paediatricians' trust in the health authorities; this can be achieved through transparent, complete and accurate information and recommendations about vaccines and VPD and through increased involvement of paediatricians in the decision-making process regarding vaccination strategies. Finally, it is necessary to reduce system barriers to achieving and maintaining vaccination uptake, through a uniform approach or guidance on regularly checking vaccination status and evidence-based interventions such as reminder/recall systems."