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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 2  |  Page : 126-131

Vaccine hesitancy among medical practitioners


1 World Health Organization, Federal University, Birnin Kebbi, Nigeria
2 Department of Microbiology, Federal University, Birnin Kebbi, Nigeria
3 Department of Demography and Social Statistics, Federal University, Birnin Kebbi, Nigeria

Date of Submission13-Jun-2018
Date of Acceptance16-Jun-2019
Date of Web Publication10-Jul-2020

Correspondence Address:
Dr. Semeeh Akinwale Omoleke
World Health Organization, Kebbi State
Nigeria
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DOI: 10.4103/smj.smj_32_18

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  Abstract 


Background: Vaccine hesitancy defined as “delay in acceptance or refusal of vaccination despite availability of vaccination services is a global phenomenon. There have been anecdotal evidence or rather poor documentation of hesitancy or noncompliance among medical practitioners in Northern Nigeria. Objective: We explored the perceptions and perspectives of doctors in Kebbi State, Nigeria, on immunization programs. Materials and Methods: We conducted this cross-sectional study involving 63 medical doctors, whose self-administered questionnaires were analyzed using descriptive statistics. Results: Only 43.55% of the doctors reported having under-five children with complete vaccination, whereas 84% of the doctors surveyed had a child or a relative with a child who had missed routine immunization (RI) previously. Approximately 66.67% and 67.74% of the doctors believed in the quality of the vaccine and capacity of the health workers to effectively deliver polio supplementary immunization activities (PSIAs), respectively. Adequate training of workers (26.23%) and public enlightenment campaigns (23.68%) were suggested as PSIAs enhancers. Collaboration with community and religious leaders (29.2%), education and public sensitization (28.09%), and improved government funding (13.48%) to improve RI were suggested. Others include incentives and fines (8.99%), adequate training of staff (10.11%), house-to-house vaccination (4.49%), and media publicity (5.62%). Conclusion: Vaccine hesitancy among medical doctors could be a threat to sustained polio interruption and efforts toward improving RI in Kebbi State. The state government and development partners should modify the current approaches to attaining polio-free certification standards and strengthen RI in the state. In addition, there is a need to improve sensitization of doctors in the state on vaccines and their safety profiles with a view to reducing vaccine hesitancy among them.

Keywords: Immunization, medical doctors, Nigeria, vaccine hesitancy


How to cite this article:
Omoleke SA, Ajibola O, Omisakin OA, Umeh GC. Vaccine hesitancy among medical practitioners. Sahel Med J 2020;23:126-31

How to cite this URL:
Omoleke SA, Ajibola O, Omisakin OA, Umeh GC. Vaccine hesitancy among medical practitioners. Sahel Med J [serial online] 2020 [cited 2020 Aug 13];23:126-31. Available from: http://www.smjonline.org/text.asp?2020/23/2/126/289352




  Introduction Top


Historically, Northern Nigeria has been plagued with challenges of vaccine hesitancy due to a number of reasons such as unmet needs, oral polio vaccine (OPV) safety, and political differences.[1],[2],[3] Vaccine hesitancy is programmatically and popularly referred to as noncompliance. Simply, vaccine hesitancy means refusal of vaccine. However, new knowledge has challenged the previous understanding of either acceptance or refusal of vaccine. According to the World Health Organization (WHO) Strategic Advisory Group of Experts, vaccine hesitancy is defined as “delay in acceptance or refusal of vaccination despite availability of vaccination services.”[4] Vaccine hesitancy is complex; is context specific; varies with time, place, and vaccine; and is influenced by factors such as complacency, convenience, and confidence.[4]

Vaccine hesitancy is a global phenomenon and has been reported in different parts of the world – Canada, France, and the United Kingdom.[1],[5],[6],[7],[8],[9] Vaccine hesitancy is not limited to the general public but has also been reported among general practitioners (medical doctors) in Europe.[8] There have been anecdotal evidence or rather poor documentation of hesitancy or noncompliance among medical practitioners in Northern Nigeria. In the past few years, the Nigerian Medical Association has been supporting the Expanded Programme on Immunization and Polio Eradication Initiatives (EPI/PEI), which hitherto had been criticized by some clinicians. Some other groups such as religious associations, religious teachers, and academia had posed resistance to vaccination, specifically OPV administration.[10] In the last decade, the polio program, with the support of health development partners, has made significant progress in re-building the confidence of health workers and the general public regarding the safety and efficacy of OPV and the continued implementation of supplemental immunization activities in interrupting polio transmission.[11] The growing confidence in the safety and efficacy of OPV in combination with concurrent implementation of other strategies of PEI will lead to the attainment of polio certification status. Unfortunately, the vestige of misconception and/or poor understanding of the PEI strategies still remains among medical practitioners, religious groups, and members of the general public.

In the light of the above, this paper explored the perceptions and views of medical doctors on this subject as they are capable of supporting public health in sustaining gains made in the areas of improvement in vaccine acceptability. Doctors are a potential asset in promoting the uptake of routine vaccination from conventional delivery sites–clinics, comprehensive health centers, and hospitals.[12] Therefore, it is germane to examine physicians' perspectives which could complement the existing strategies. Doctors' views would be relevant in improving the uptake of vaccines for vaccine-preventable diseases (VPDs). This is relevant in revitalizing primary health-care services and reversing the trend of low immunization coverage in Nigeria.


  Materials and Methods Top


Study site

This study was carried out in Kebbi – a state in Northwest Nigeria. Kebbi State is situated between latitudes 10° 8′ N and 13° 15′ N and longitudes 3° 30′ E and 6° 02′ E, with an approximate surface area of 36,229 km 2.[13] The state's demographic features include mainly individuals from the Hausa ethnic group and Islamic religion, comprising 21 local government areas (LGAs). Kebbi State has an estimated population of 4,531,129 based on 2006 projected census figures on a total area of 36,800 km 2. Kebbi State has one tertiary health facility and 31 secondary health-care facilities in 21 LGAs. There are 334 doctors registered in practice in the state according to the records of the Kebbi State Chapter of Nigerian Medical Association.

In respect of PEI in Nigeria, Kebbi State is classified as Tier 2 high-risk state in view of its low immunization coverage, presence of nomadic and hard-to-reach population, pockets of noncompliance (vaccine hesitancy), and geographical contiguity with Sokoto State where circulating vaccine-derived polio virus was recently isolated.[14]

Study design and data collection

This was a cross-sectional study carried out on September 23, 2017, when the WHO, Kebbi State branch organized a 1-day seminar on cholera and polio for all doctors in active practice in the state. All hospitals within the state were notified in advance of the seminar in order to ensure proper representation. The seminar had in attendance eighty doctors, and each participant was handed a questionnaire to fill. Eighty questionnaires were distributed to the participants at the seminar. The questionnaires comprised questions relating to sex, career level, years in clinical practice, marital status, number of children, whether they have a child or relative's child that had missed routine polio immunization, faith in safety of the vaccine, and suggestions of other strategies that could improve efforts toward achieving polio certification.

Data analysis

Data were collated and analyzed with Microsoft Excel and Stata version 12 software (College Station, Texas, USA) to generate differential descriptive statistics including frequency tables that showed the frequency and percentage distribution of observations with categorical responses. Response rate of the participants was 78.8%.

Ethical consideration

We sought and got approval from the Health Research Committee of the Kebbi State Ministry of Health no: 104:5/2019 dated 12th May 2019. We obtained written consents as captured in the administered questionnaires from all the medical practitioners who participated in the study, after explaining to them the purpose of the study. In addition, this study was conducted in compliance with the principles of the Helsinki declaration.[15] Lastly, the study did not involve any invasive approach on participants.


  Results Top


Demographics and clinical experience

Following the distribution, completion, and analysis of the questionnaires, the ratio of male-to-female doctors was 4.2:1. In terms of career level, the distribution of the respondents was house officers (6.35%), medical officers (60.32%), registrars (19.05%), senior registrars (1.59%), and consultants (12.7%). In terms of their clinical years of experience, respondents who had practiced between 1 and 10 years constituted 75.86%, 11 and 20 years constituted 18.97%, 21 and 30 years constituted 3.45%, and 31 and 40 years constituted 1.72%. The respondents' age distribution was 25% between ages 21 and 30 years, 52.27% between 31 and 40 years, 18.18% between 41 and 50 years, and 4.55% between 51 and 60 years [Table 1].
Table 1: Distribution of respondents' characteristics

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Participation of doctors' families in polio supplemental immunization activities

In order to determine the participation of the family members of doctors in polio supplemental immunization activities (PSIAs), we analyzed the responses of the doctors to questions relating to the participation of their children and relatives in routine immunization (RI) and PSIAs [Table 2]. Approximately 43.55% of the doctors reported having under-five children with complete vaccination, whereas 56.45% reported having under-five children without complete vaccination. Approximately 84% of the doctors surveyed had a child or a relative, with a child who had missed RI previously. However, all (100%) the doctors surveyed claimed that none of their biological children or child of a relative was affected by polio. We further asked the doctors if they believed health workers carrying out PSIAs were well trained and if the doctors believed in the quality of the vaccine administered to children during the campaign. The responses from the doctors revealed that 66.67% and 67.74%, respectively, believed in the quality of the vaccine and capacity of the health-care workers to deliver PSIAs effectively.
Table 2: Distribution of respondents' participation and acceptance of immunization during the PSIAs

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To determine why the response of doctors and their family members was suboptimal in PSIA uptake, we asked the respondents to suggest what could be done to improve polio supplementary immunization campaigns. Most of the respondents suggested adequate training of workers (26.23%) and public enlightenment campaigns (23.68%) as activities that could enhance PSIAs in Nigeria. The respondents also suggested that program managers and policymakers can improve RI in the country mostly through collaboration with community and religious heads (29.21%), education and public sensitization (28.09%), and improved government funding (13.48%). Other suggestions include incentives and fines (8.99%), adequate training of staff (10.11%), house-to-house vaccination (4.49%), and media publicity (5.62%).


  Discussion Top


Development of vaccines and vaccination programs has been widely applauded as one of the most important public health initiatives that has led to a signification reduction in morbidity and mortality from VPDs. Despite this laudable achievement through vaccination, vaccine hesitancy has been reported in many countries and across social classes, including medical professionals and scientists.[5],[6],[8],[9],[10],[11],[16],[17] Vaccine hesitancy is inimical to public health as it has been associated with setbacks in disease elimination and eradication efforts (such as measles and poliomyelitis) in different parts of the world.[8],[10]

In this study, a large proportion of the respondents (doctors) have children or relatives living with them that have participated in PSIAs in Kebbi State, Nigeria. This is largely consistent with the statistics that 67.7% of the respondents reported that they believe in the quality (efficacy) of vaccines administered during polio campaigns (PSIAs).

Only 16% of the respondents' children missed RI appointments, while the proportion of respondents' children below 5 years who have received complete RI antigens was very low. The RI completion rate of respondents' children below 5 years is below the national target of 80%,[14] a worrisome development because all the respondents we medical doctors. A small proportion of the respondents indicated noninvolvement of their children or relatives in PSIAs, and this poses some risks to the attainment of polio-free status, especially with suboptimal RI completion rate among the surveyed population. Findings from this study are somewhat higher than the reported prevalence of vaccine hesitancy among general practitioners in France, which put the prevalence at 14% for moderate-to-high hesitancy (opposed) toward vaccination.[16] The hesitancy observed among doctors might be as a result of influence of religion, limited knowledge of vaccine development and their safety profile, and previous antivaccination sentiments.

Our finding of low RI completion rate among doctors' children could be a pointer to low immunization coverage in the general population in Kebbi State, as the latest National Immunization Coverage Survey indicated low OPV3 and Penta3(12.1% and 11.3%, respectively).[18]

In a multicountry (13 countries) study conducted between September and December 2013, confidence issues regarding the safety and schedule have been reported among doctors in some countries borne out of paucity of knowledge about vaccine and vaccination schedule.[5] The low RI uptake rate among the respondents' children <5 years may be due to their dissatisfaction with the current approaches to interrupt poliovirus transmission in Nigeria. About half of the respondents suggested a change of approach, especially improved public enlightenment and adequate training of personnel. They also suggested better partnership and collaboration with community and religious leaders, adequate cold chain for vaccine storage, improved funding for immunization services, and provision of incentives to encourage families to fully immunize their children. Some of the aforementioned approaches are currently being implemented within the PEI/EPI in Nigeria such as media engagement and partnership with traditional and religious institutions. However, challenges still persist in the areas of cold chain facilities and funding of immunization services. The use of incentive has been applied to PSIAs in Northern Nigeria, especially in communities with high numbers of noncompliance (vaccine refusal). This has achieved significant successes in conjunction with other demand-creation interventions such as the use of Polio Survivor Groups, Quranic Teachers' Engagement, Health Camp, and Directly Observed Polio Vaccination among others.[3],[11] The call for incentivization by doctors in this study could be a “quick-win” which is not sustainable for a routine health intervention such as the National Routine Immunization Programme (EPI).

Furthermore, the low demand for RI antigens, including polio vaccines, may be due to low risk perception of the respondents, as none of the respondents' children had suffered polio. It may be that the respondents perceive polio and other VPDs as little threat to their children, who feed well and are likely to be healthy.

However, this study has some limitations. One of the limitations is the fact that we considered only medical doctors, though vaccine hesitancy may be prevalent among other health workers such as nurses, nutritionists, pharmacists, and community health workers. Another limitation is the possibility of concealment of information by the doctors due to stigmatization associated with polio because the study approach was self-reported. However, we are of the opinion that the information provided by the respondents is largely reliable. Finally, we were only able to sample a small number of doctors in the state using convenience sampling technique, thus limiting the generalization of the study findings. Despite the aforementioned limitations, this study has provided important public health data for government and stakeholders in the health sector to consider in the drive to achieving a polio-free status for Nigeria by 2019.


  Conclusion Top


Our results demonstrate high vaccine hesitancy among medical doctors in the study population and this is a potential threat to the gains made toward achieving interruption of vaccine preventable diseases such as poliovirus transmission. We recommend sensitization of doctors on vaccines uptake and safety.

Limitations

Our findings are based mainly on self-reported attitude towards vaccination.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dubé E, Vivion M, MacDonald NE. Vaccine hesitancy, vaccine refusal and the anti-vaccine movement: Influence, impact and implications. Expert Rev Vaccines 2015;14:99-117.  Back to cited text no. 1
    
2.
Kaufmann JR, Feldbaum H. Diplomacy and the polio immunization boycott in Northern Nigeria. Health Aff (Millwood) 2009;28:1091-101.  Back to cited text no. 2
    
3.
Warigon C, Mkanda P, Muhammed A, Etsano A, Korir C, Bawa S, et al. Demand creation for polio vaccine in persistently poor-performing communities of Northern Nigeria: 2013-2014. J Infect Dis 2016;213 Suppl 3:S79-85.  Back to cited text no. 3
    
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MacDonald NE; SAGE Working Group on Vaccine Hesitancy. Vaccine hesitancy: Definition, scope and determinants. Vaccine 2015;33:4161-4.  Back to cited text no. 4
    
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Dubé E, Gagnon D, Nickels E, Jeram S, Schuster M. Mapping vaccine hesitancy – Country-specific characteristics of a global phenomenon. Vaccine 2014;32:6649-54.  Back to cited text no. 5
    
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Dubé E, Gagnon D, Ouakki M, Bettinger JA, Guay M, Halperin S, et al. Understanding vaccine hesitancy in Canada: Results of a consultation study by the Canadian immunization research network. PLoS One 2016;11:e0156118.  Back to cited text no. 6
    
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Paterson P, Larson H, Paterson CP. The Perceived Full Public Health Value of Vaccines and Vaccine Hesitancy among Patients and Providers Team Lead. Vaccine 2016:34;6700-706.  Back to cited text no. 7
    
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Triggle N. Wakefield and Autism: The Story that will not go Away BBC News. 28 January, 2010. Available from: http://news.bbc. co.uk/1/hi/health/8481583.stm. [Last accessed on 2018 May 15].  Back to cited text no. 8
    
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Verger P, Fressard L, Collange F, Gautier A, Jestin C, Launay O, et al. Vaccine hesitancy among general practitioners and its determinants during controversies: A national cross-sectional survey in France. EBioMedicine 2015;2:891-7.  Back to cited text no. 9
    
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Ghinai I, Willott C, Dadari I, Larson HJ. Listening to the rumours: What the northern Nigeria polio vaccine boycott can tell us ten years on. Glob Public Health 2013;8:1138-50.  Back to cited text no. 10
    
11.
Nasir SG, Aliyu G, Ya'u I, Gadanya M, Mohammad M, Zubair M, et al. From intense rejection to advocacy: How Muslim clerics were engaged in a polio eradication initiative in Northern Nigeria. PLoS Med 2014;11:e1001687.  Back to cited text no. 11
    
12.
Wheeler M, Buttenheim AM. Parental vaccine concerns, information source, and choice of alternative immunization schedules. Hum Vaccin Immunother 2013;9:1782-9.  Back to cited text no. 12
    
13.
Jirgi AJ, Grove B, Henry J, Nmadu NJ. Risk attitude of monocrop and intercrop farmers in Kebbi state, Nigeria. J Econ Sustain Dev 2016;7:140-9.  Back to cited text no. 13
    
14.
National Primary Health Care Development Agency; 2017. p. 1-51. Available from: http://polioeradication.org/wp-content/uploads/2017/03/NPEEP-2017-March-2017-FINAL.pdf. [Last accessed on 2018 May 15].  Back to cited text no. 14
    
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World Medical Association. World medical association declaration of Helsinki. Ethical principles for medical research involving human subjects. Bull World Health Organ 2001;79:373-4.  Back to cited text no. 15
    
16.
Verger P, Collange F, Fressard L, Bocquier A, Gautier A, Pulcini C, et al. Prevalence and correlates of vaccine hesitancy among general practitioners: A cross-sectional telephone survey in France, April to July 2014. Euro Surveill 2016;21. pii: 30406.  Back to cited text no. 16
    
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Kapp C. Surge in polio spreads alarm in Northern Nigeria. Rumours about vaccine safety in Muslim-run states threaten WHO's eradication programme. Lancet 2003;362:1631-2.  Back to cited text no. 17
    
18.
National Primary Healthcare Development Agency and National Bureau of Statistics. Nigeria, National Immunisation Coverage Survey 2016/17, Final Report. Abuja: National Primary Healthcare Development Agency and National Bureau of Statistics; 2017.  Back to cited text no. 18
    



 
 
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