Knowledge, Attitude and Practice of Primary Care Physicians Toward Adult Vaccination in Abha City

Aim of study: To assess knowledge, attitude and practice of primary care physicians offering primary health care (PHC), toward adult vaccination and their own vaccination coverage as well as to identify reasons for low vaccination coverage. Methodology: A cross-sectional study design, this study included 103 PHC physicians in Abha City. A self-administered questionnaire was designed by the researcher for data collection. Results: About three fourths of PHC physicians (73%) had poor knowledge, while 21% had moderate knowledge and only 6% had good knowledge, while 41% had positive attitude toward adult vaccination, 49% had neutral attitude while 10% had negative attitude. Most PHC physicians (70%) had poor practice regarding adult vaccination, while 20% had moderate practice and 10% had good practice. PHC physicians’ knowledge was significantly better among older and non-Saudi physicians (p<0.001 and p=0.001, respectively). PHC physicians’ positive attitude toward adult vaccination was significantly higher among female participants (p=0.013), among Non-Saudi physicians (p=0.004) and among those with experience in primary health care more than 10 years (p=0.044). PHC physicians’ good practice regarding adult vaccination was significantly higher among older physicians and among those with experience in primary health care more than 10 years (p=0.004). The most frequently stated reasons for low adult vaccination coverage were “Lack of coordinated immunization programs for adults” (63.1%), “Physicians do not inform patients about adult vaccination because they do not have enough time” (61.2%) and “Lack of availability of up-to-date records and recording systems” (55.3%). Conclusions: Knowledge of PHC physicians in Abha City regarding adult vaccination is suboptimal. Most of them do not have negative attitude toward adult vaccination. Their practice regarding adult vaccination is mostly poor. There are several obstacles against implementing vaccination of adults.


Introduction
Adult vaccination has gained as much attention as childhood vaccination nationwide and worldwide in recent years.Several studies have been performed with a variety of suggestions regarding adult vaccination [1][2][3][4] .But still, vaccination is not seen as a part of adult health care services, and adult vaccination programs are not as effective and as approachable as they are in childhood 4,5 .7][8] .An estimated 50,000-90,000 Americans die of vaccine preventable diseases each year, the vast majority of these being adults.With the recent emergence of viral strains and bacterial organisms that have had more serious consequences in healthy young adults, routine vaccination of this population is a growing necessity.Furthermore, the healthcare cost of vaccine preventable diseases (VPDs) is substantial.For example, the yearly national economic burden of influenza disease is estimated to be $10.4 billion in direct medical costs and a total economic burden of over $87 billion 9 .Because of the nature of transmissible diseases, immunization is important not only for an individual's health, but also for the health of the community at large 10 .In Saudi Arabia, until very recently vaccination has been considered as a special procedure for children, and apart from some exceptional cases and individual applications, adult vaccination has been neglected.Planning, coordination and continuity in administration are all very important issues in obtaining success 11 .Increasing the awareness of physicians, in other words, dealing with the lack of knowledge, which is accepted as one of the reasons for insufficient adult vaccination, and implementing them to give the necessary importance, will provide success in adult vaccination 12 .Physicians should evaluate the adults they see in hospitals or polyclinics, whether healthy or ill, regarding immunization against preventable diseases.They should not miss the opportunity of completing missing vaccines; they should inform the patients about the diseases and the importance of vaccination 11 .In recent years, new vaccines such as herpes zoster and human papillomavirus have become available for adults.Despite these advances, the vaccination rates of adults in Saudi Arabia are low, resulting in many adults remaining vulnerable to vaccine preventable diseases 10 .Common reasons for incomplete immunization in adulthood include: 12 Lack of recognition of the importance of adult immunization; lack of recommendation from health care providers; lack of health care provider knowledge about adult immunization and recommended vaccines; misrepresentation/misunderstanding of the risks of vaccine and benefits of disease prevention in adults; lack of understanding of vaccine safety and efficacy; missed opportunities for vaccination in health care providers' offices, hospitals and nursing homes; lack of publicly-funded vaccine and reimbursement to vaccine providers; lack of coordinated immunization programs for adults; lack of regulatory or legal requirements; fear of injections; lack of availability of up-to-date records and recording systems.Methodology Setting: This study was conducted in Abha City, Asser Province, Saudi Arabia, on the slopes of Al-Sarawat Mountains.In Abha City, there are 47 primary health care centers, in which 138 physicians are working.The study was conducted at the Ministry of Health PHC centers in Abha City.Study design: A cross sectional study Study population: PHC physicians (N=138) working in the primary health care centers belonging to the MOH in Abha city in 2015.

Sample size and sampling technique:
Owing to the relatively small number of PHC physicians, all of them were invited to participate in the study.

Data collection tool:
The researcher used a selfadministered questionnaire that was previously used in a similar Turkish study and proved to be valid and reliable. [12]Apart from the questions revealing the descriptive characteristics, their vaccination coverage, their relatives vaccination coverage, which adult vaccines they knew, and their attitude towards suggesting them to their patients were all inquired.To establish which vaccines they would suggest, they were asked to write the vaccines in some given situations.The 2009 report from the Center of Disease Control and Prevention (CDC) was taken into account in the preparation of the questions regarding risk factors and the age at which the vaccinations should be applied 4 .

Data collection technique:
The researcher distributed the self-administered questionnaire during the working hours; care was taken to not disturb the physicians.The researcher rendered himself available to clarify any issue and the questionnaires were collected on the same day.This duration of data collection was one month.Data entry and analysis: Collected data were verified by hand then were coded and entered into a personal computer.Statistical analysis was conducted using the Statistical Package of Social Sciences (SPSS version 20.0 for Windows, SPSS Inc., Chicago, IL, USA).Data were shown as frequency and percentage.For the comparison of categorical data, Chi-square test (for small frequencies) was applied.P values less than 0.05 were considered as statistically significant.Pilot study: A pilot study was conducted on 10 family medicine residents in Aseer Program over one week.It helped in the adaptation of the study questionnaire.The results were not included in the main report.Ethical considerations: Before starting data collection, the researcher obtained an approval letter from Aseer Directorate of Health for Primary Health Care.The study questionnaire was anonymous.Participants were assured that results of this study would not be used for performance appraisal of the individuals.To maintain the confidentiality from the health authority, participant physicians were asked to send the completed questionnaires directly to the researcher.Budget: This study was self -funded.
Regarding adult vaccination, about three fourths of primary health care physicians 75(73%) had poor knowledge, while 22(21%) had moderate knowledge and only 6(6%) had good knowledge.
Table (4) shows that the most primary health care physicians 93(90.3%)agree that adult vaccination a protective modality, that pregnant women should be asked about their vaccination coverage 87(84.5%),that there is a need to ask patients at risk about their vaccination coverage 76(73.8%)and that it is important to ask elderly patients about their vaccination coverage 64(62.1%).However, about one fourth of participants think that there is no need to establish antibody levels before hepatitis B vaccination 28(27.2%)and another one fourth of them think that their knowledge about adult vaccination is insufficient.Forty-seven (41%) of primary health care physicians had positive attitude toward adult vaccination, 51(49%) had neutral attitude while 51(10%) had negative attitude.Table (5) shows that about three fourths of primary health care physicians 78(75.7%) received influenza and hepatitis B vaccines, while 42(40.8%)received tetanus vaccine, 22(21.4%) received the pneumococcal vaccine and 14(13.6%)received the HPV vaccine.About half of participants 58(56.3%)vaccinated their first degree relatives against influenza, while other vaccines were less frequently applied, e.g., hepatitis B 42(40.8%) and tetanus 26(25.2%).Most participants 89(86.4%)recommended the influenza vaccines to their patients, while other vaccines were less frequently recommended, e.g., tetanus 74(71.8%)and hepatitis B 63(61.2%).The study revealed that primary health care physicians 72(70%) had poor practice regarding adult vaccination, while 21(20%) had moderate practice and 10(10%) had good practice.Table (6) shows that primary health care physicians' knowledge regarding adult vaccination differed significantly according to their age with highest proportion of those with poor knowledge among the youngest age group and the lowest proportion of those with poor knowledge among older age groups (p<0.001).Saudi physicians had significantly higher proportion of poor knowledge than non-Saudi physicians (80% vs. 60.5%,respectively, p=0.001).However, primary health care physicians' knowledge grades did not differ according to their gender, qualification, position or experience in primary health care practice.Table (7) shows that primary health care physicians' positive attitude toward adult vaccination was significantly higher among female participants (p=0.013),among Non-Saudi physicians (p=0.004),among registrars and senior registrars (p=0.001) and among those with experience in primary health care more than 10 years (p=0.044).However, primary health care physicians' attitude grades did not differ according to their age or qualification.Table (8) shows that primary health care physicians' good practice regarding adult vaccination was significantly higher among participants older than 40 years (p<0.001),among MBBS qualified physicians (p=0.018), and among those with experience in primary health care more than 10 years (p=0.004).However, primary health care physicians' practice grades did not differ according to their gender, nationality or position.
Table (9) shows that the most frequently stated reasons for low adult vaccination coverage were "Lack of coordinated immunization programs for adults" (63.1%), "Physicians do not inform patients about adult vaccination because they do not have enough time" (61.2%) and "Lack of availability of up-to-date records and recording systems" (55.3%).Discussion Globally, adult vaccination has recently gained as much attention as childhood vaccination worldwide. 11However, vaccination of adults has not been seen as a part of adult health care services, and adult vaccination programs are not as effective and as approachable as they are in childhood 5 .This study aimed to assess the knowledge, attitude and practice of primary health care physicians in Abha City regarding adult vaccination.Results of this study showed the variability in qualifications and positions among participant primary health care physicians.About two thirds of participants were general practitioners with MBBS Degree, while one third of them had Diploma, Master, PhD or equivalent.Almost half of participants were general practitioners, one third was residents, and the rest were registrars/senior registrars or consultants.This finding is in agreement with that of that of Bovier et al. 5 who noted the wide variability in primary care physicians' qualifications and specialties in Geneva, Switzerland, where almost half of physicians were general practitioners and the other half were general internists or other specialties.Results of the present study revealed that, regarding primary health care physicians' knowledge about adult vaccination, only 6% had good knowledge, 21% had moderate knowledge, while 73% had poor knowledge.Regarding vaccinating adults in high risk groups, participants' most correct responses were related to influenza vaccine followed by pneumococcal vaccines, while the knowledge of most participants about all other vaccines were deficient.Regarding their knowledge about vaccines administered to adults in some disease groups, the highest correct responses were related to influenza and pneumococcal vaccines, while the knowledge of most participants about all other vaccines were deficient.In USA, Tan et al. 23 reported that primary care physicians had low knowledge regarding adult vaccination.Hurley et al. 24 explained the variability in primary health care physicians' knowledge regarding different adult vaccines by that, in primary care practice, an environment with lower perceived priority of certain vaccines could have implications for knowledge and vaccine delivery.Several factors contribute to primary health care physicians' perceptions that some vaccines are less important than other preventive services, including evidence supporting the use of the preventive service, access to the service, patient demand for the service, physician experience treating certain diseases, clarity of the guideline recommending the service, and whether or not the service is tracked as a performance measure for the practice.The poor physicians' knowledge regarding some vaccines, e.g., tetanus, compared with better knowledge regarding other vaccines, e.g., influenza and pneumococcal vaccines, may reflect the difficulty some physicians have in providing these vaccines to the adult population.The Centers for Disease Control and Prevention 15 reported that, the adult vaccination schedule is complex since several vaccine recommendations are risk-based or require knowledge of vaccination history, which is often not available.Most physicians agreed that the age-based and medical conditionbased indications for vaccination were difficult to follow.These findings are in agreement with those of MacDougall et al., 16 in Canada, who noted that despite guidelines for adult vaccination, there are substantial gaps in knowledge among healthcare providers.Findings of the present study showed that 41% had positive attitude toward adult vaccination.Most primary health care physicians agreed that adult vaccination a protective modality, that pregnant women should be asked about their vaccination coverage, that there is a need to ask patients at risk about their vaccination coverage and that it is important to ask elderly patients about their vaccination coverage.However, about one fourth of participants think that there is no need to establish antibody levels before hepatitis B vaccination and another one fourth of them think that their knowledge about adult vaccination is insufficient.These findings are in accordance with those of Baykan et al., 11 in Turkey, who found that 83% of primary health care physicians believe that vaccinating adults is a modality of protection, 49.6% agreed to question pregnant women about their vaccination coverage, 68.8% agreed that there is a need to ask adult patients at risk about their vaccination coverage, but 18.4% agreed to ask elderly patients (aged 65 years or more) about their vaccination coverage, 12.4% stated that there is no need to establish antibody levels before hepatitis B vaccination and 23.4% of primary health care physicians find their knowledge about adult vaccination as insufficient.MacDougall et al. 16 found that about half of physicians have positive attitudes toward adult vaccination, where 46.9% of physicians believed that vaccines are more important for children than adults, 54.7% agreed that it is difficult to keep up with vaccination recommendations for adults.Findings of the present study showed that most primary health care physicians had poor practice regarding adult vaccination, while only 10% had good practice.About three fourths of primary health care physicians received influenza and hepatitis B vaccines, while 40.8% received tetanus vaccine, 21.4% received the pneumococcal vaccine and 13.6% received the HPV vaccine.In addition, about half of participants vaccinated their first degree relatives against influenza, while other vaccines were less frequently applied.Moreover, most participants recommended the influenza vaccines to their patients, while other vaccines were less frequently recommended.Pickering et al. [17] stated that the risk of health personnel of being exposed to diseases preventable by vaccination and of infecting their patients is substantially high.Health personnel should get a repeat dose of tetanus.All people dealing with blood and blood products should be vaccinated against hepatitis B, and every health personnel should get an influenza vaccination.Apart from these, some other vaccinations are administered in special situations.Vaccination against influenza was received by most participant primary care physicians in the present study (75.7%).Lower rates have been reported by Baykan et al., [11] in Turkey (58.5%).Moreover, vaccination rates of physicians' first degree relatives were also low.It is to be noted that influenza vaccination has been suggested to the health personnel by CDC, since 1980's.The mainstay of this suggestion is that sick health personnel pose the risk of infecting patients at work, and in places with non-vaccinated health personnel, hospital-borne influenza epidemics can be seen [18][19][20] .Szucs et al. 21added that vaccination of health personnel decreases patient morbidity and mortality and days out of work, and provides economic contribution to healthcare organizations.Nevertheless, several studies in Australia, Italy and United States of America indicated that the influenza vaccination rates among health personnel were below 50%  . Vacciation against hepatitis B was received by most participant primary care physicians in the present study (75.7%), while 40.8% had their first degree relatives being vaccinated, while 61.2% of participants suggested it to their patients.Aka and Dündar 24 stated that blood-borne infectious diseases pose an occupational hazard for health workers.In a university hospital, they reported that 37% of health personnel that had the risk of contact with patients' blood were vaccinated against hepatitis B. In Turkey, Demir et al. 25 reported that vaccination rate against hepatitis B was 55.8% while Uzun et al. 26 reported a vaccination rate of 88.7% among residents of a university hospital, while Baykan et al. 11 reported that 67.0% of physicians were vaccinated against hepatitis B. In studies from France and USA the vaccination rates against hepatitis B were around 80% -90% [27][28] .In USA, Campos-Outcalt et al. 29 noted that 80% of family physicians reported providing most routinely recommended adult vaccines at their practice primary health care sites.The present study showed that primary health care physicians' knowledge regarding adult vaccination differed significantly according to their age with highest proportion of those with poor knowledge among the youngest age group.Saudi physicians had significantly higher proportion of poor knowledge than non-Saudi physicians.Moreover, physicians' positive attitude toward adult vaccination was significantly higher among female participants, among non-Saudi physicians, among registrars and senior registrars and among those with experience in primary health care more than 10 years.In addition, physicians' good practice regarding adult vaccination was significantly higher among participants older than 40 years, among MBBS qualified physicians, and among those with experience in primary health care more than 10 years.Perhaps better knowledge regarding adult vaccination among older physicians can be expected.However, a higher proportion of poor knowledge among Saudi physicians may be explained by the fact that in Saudi Arabia, the employment of non-Saudi physicians follows strict criteria to employ only the best knowledgeable physicians. Inaddition, non-Saudi physicians have to follow the guidelines very carefully to avoid termination of their contracts.All these points do not perfectly apply to Saudi primary health care physicians.Hence, the significantly poorer knowledge among Saudi physicians.Hurley et al. 14 stated that primary health care providers had positive attitude toward adult vaccination, which was significantly higher among females and those with more experience in medical practice.Abramson and Levi 6 and Baykan et al. 11 found that vaccination practices for adults were higher in female physicians compared to male physicians, but with no significant differences.Results of the present study showed that the most frequently stated reasons for low adult vaccination coverage were "Lack of coordinated immunization programs for adults", "Physicians do not inform patients about adult vaccination because they do not have enough time" and "Lack of availability of upto-date records and recording systems".Several studies reported reasons for low rates of adult vaccination.Stated reasons comprised lack of knowledge among primary care physicians, preoccupations concerning the efficacy and side effects of vaccines, not being under the coverage of health insurance, the lack of a national health policy regarding adult vaccination and the economic cost that it brings to the government can all be considered as reasons for insufficient adult vaccination 30-31-.Bovier et al. 5 stated that the most important reason behind missed opportunities for adult vaccination is the lack of the motivation physicians should provide to their patients.Johnson et al. 42 reported that the reasons for low vaccination rates were; the refusal of patient to come in for controls, there being no reminding warning system for adult vaccination, and refusal of vaccination itself.Baykan et al. 11 found that the first three factors for low adult vaccination rates were lack of time, physicians prioritizing treatment modalities, and patients' refusal of vaccination.Nevertheless, the main factor for low adult vaccination rates remains to be the physicians' lack of knowledge.The National Foundation for Infectious Diseases 33 noted that adult immunization schedule may not be well understood by primary health care providers. Th first step toward increasing adult vaccination rates is to communicate who should be vaccinated and when.Vaccination barriers exist among healthcare providers and delivery systems.

Conclusions
Based on results of the present study, the following can be concluded: • To repeat this study in other areas of the Kingdom of Saudi Arabia so as to obtain the global view about knowledge, attitude and practice of primary health care physicians regarding adult vaccination and to identify reasons for low rates for receiving vaccines in Saudi Arabia.