Assessment of the knowledge, practice, and barriers of physicians in Lagos about respiratory diseases preventable vaccines

INTRODUCTION

Elderly people and adults with chronic diseases or compromised immune status are at increased risk of respiratory infections, with pneumonia being the most common serious presentation and a significant cause of morbidity and mortality.^[1] Most European countries, as well as North American Countries, have well-established recommendations for adult vaccination, but this seems to be less popular or at best an evolving development in Africa.^[1,2] The commonly recommended adult respiratory disease preventable vaccines include pneumococcal, influenza, HIB (Haemophilus influenza type B), and most recently COVID-19 vaccine.^[2] The recommendations for most of these vaccines in Nigeria for adults are based on international guidelines and expert opinion locally.^[3,4]

Childhood vaccination coverage in Nigeria has significantly improved in the past two decades, averting millions of deaths per year.^[5,6] However, adult vaccination coverage remains poor.

The Nigerian government funds childhood vaccination, while the adult vaccine except that for COVID-19 is largely funded out of pocket and not covered by the government initiatives.

Several studies have evaluated factors affecting vaccine coverage. Logan et al., in a study in the United States of America, noted that many groups in the United States are to yet benefit from potentially life-saving influenza vaccination due to cost, insurance status, language differences, underestimation of personal risk, misunderstanding of vaccination risks, and mistrust toward the health-care system.^[7] Al Awaidy et al. also noted that despite existing policies, influenza vaccination coverage remains far below the WHO recommendations in the Middle East and Northern Africa as a result of decreased awareness and effective implementation of policies with the collaboration of stakeholders.^[8] Vaccine coverage may also be affected by the recommendations of the healthcare providers, even in patients with a negative attitude toward vaccination.^[9-11] The level of awareness and knowledge of physicians may also affect the recommendation of these vaccines. Vora and Shaikh reported that 3.97%, 53.08%, and 42.95% of physicians had high, medium, and low levels of awareness about influenza vaccination, respectively, in India in a multicenter cross-sectional survey.^[12]

There are gaps in the adequate recommendation of adult immunization in Africa. We hypothesized that the barriers to adult vaccination in Africa are multifactorial and include access to vaccine availability, cost, and lack of adequate recommendations by healthcare professionals.

This study aimed to evaluate the perceptions, practice, and barriers of the physician in recommending adult vaccines. This will help to highlight some of the major challenges affecting adult vaccine coverage and will be useful in guiding the focus of intervention by policymakers and stakeholders at the state and national levels on how best to improve the adult vaccine coverage.

MATERIALS AND METHODS

RESULTS

The sociodemographic characteristics of the participants are shown in [Table 1]. Ninety-seven (97) physicians completed the questionnaire. Most of the respondents were consultants 54 (55.7%). The mean age of the respondents was 39.54 ± 6.2. Most physicians were female (55:56.7%), in the age group ages 36–45 (59:60.8%), internal medicine physicians (58:59.8%), and practicing in tertiary public (75:77.3%) hospitals and have practiced for 10–14 years (37:38.1%).

DISCUSSION

The CDC recommends immunization schedules for children, adolescents, and adults.^[14] The recommendations are available to both healthcare professionals and the general public. Although the Nigerian childhood immunization program has been very successful, the same level of success has not been achieved in adults.^[15-17] This study evaluated the knowledge, practice, and barriers of a physician in recommending adult vaccines. We found that the knowledge of physicians about respiratory disease preventable vaccines was below average. However, physicians who had completed their training have better knowledge compared to the resident doctors in training. Internal medicine physicians reported better knowledge about the vaccine compared to other physicians. Most physicians recommend vaccines for patients with chronic lung diseases. About two-thirds of physicians recommended the common vaccines including pneumococcal and influenza vaccines. The common barriers in recommending vaccines were unavailability, poor reminder systems, high cost of vaccines, inadequate insurance coverage, vaccine shortage, and side effects concerns.

The average knowledge of physicians about respiratory disease preventable vaccines found in this study is similar to reports from previous studies. Amin et al. reported that the overall knowledge of physicians about influenza and pneumococcal vaccines was inadequate in Saudi Arabia.^[18] James et al. in Sierra leone examined the knowledge of health workers and reported that close to half, 321 (46.0%) of healthcare workers were not aware of the influenza immunization guidelines published by the Advisory Committee on Immunization Practices and Centre for Disease Control.^[19] Physicians who had completed their training have better knowledge compared to the residents. This is similar to the report of Evren et al. who noted a higher knowledge of pneumococcal vaccine among 76.1% of physicians in Cyprus compared to GP.^[20] Furthermore, in this study, Internal Medicine physicians reported better knowledge about the vaccines compared to other physicians. This finding is similar to the report from a multicenter cross-sectional study in India, where the level of knowledge about different types of adult respiratory disease preventable vaccines varies among doctors based on specialties, and regional location.^[12]

Most physicians recommended vaccines for patients with chronic lung diseases, ages >65, close contact with someone at high risk, asplenia, and weak immune systems. Satman et al. reported physicians’ recommendations of influenza and pneumococcal vaccinations up to 87.9% and 83.4%, respectively, among diabetic patients in Turkey.^[21] Nichol and Zimmerman also reported that most physicians recommended pneumococcal and influenza vaccines for their high-risk and elderly patients in another study in the United States of America.^[22] This calls for the attention of physicians to routinely identify patients who will benefit from the recommended vaccines. About two-thirds of physicians recommended the common vaccines including pneumococcal and influenza vaccines. This is lower than the report of Gramegna et al. in a surveillance study in Italy who noted the recommendation of influenza vaccine among 80% of physicians.^[23] Similarly, Vora and Shaikh reported a significant recommendation for influenza vaccine of about 78% among physicians in India in a survey despite their low knowledge.^[12] Evren et al. also noted that the rate of influenza vaccination among specialists was high.^[20] This implies that the practice of recommending vaccines for an adult is not optimal and may be influenced by the knowledge of the physician. This is a potential target area to address to improve adult vaccine coverage.

One of the main barriers toward optimal adult vaccination coverage includes a lack of physician recommendations for different reasons ranging from cost, access, availability, and level of awareness to perceptions.^[24] In this study, we found the high cost of the vaccine, vaccine shortage, inadequate insurance coverage, side effects concerns, and poor reminder systems as the barriers representing core areas affecting respiratory adult vaccines coverage. Duque et al. reported in South Africa that healthcare workers who reported getting the influenza vaccine themselves and offering their patients vaccines were familiar with the guidelines.^[25] Navin also reported that the main drivers that may lead a physician to sometimes not recommend vaccination include vaccination concerns about efficacy and safety, the physician’s mindset, and lack of availability of the vaccine.^[26] The other key factors influencing physicians to recommend or prescribe adult vaccines, in general, were individual’s condition and age, recommendations from health authorities, and tolerability of the vaccine.^[26] There is a need for all the stakeholders to work on interventions to address most of the barriers identified to improve adult vaccine coverage in Nigeria.

CONCLUSION

This study evaluated the knowledge, practice, and barriers to adult respiratory disease preventable vaccines among physicians in Lagos. Our findings suggest that the knowledge of physicians is below average. However, the majority recommend common vaccines including pneumococcal conjugate, influenza, and COVID 19 vaccines. The major barriers to vaccination include availability, cost, and fear of side effects. The results of this study suggest that more emphasis should be placed on increasing awareness about these vaccines among physicians. Furthermore, there should be an improvement in the availability of vaccines.