Preliminary survey of knowledge, attitudes and practices among nurses regarding seasonal influenza and influenza vaccination

Health care workers are at risk of influenza through occupational exposure. Uptake of influenza vaccine is poor even in countries where it is provided free. We sought to determine the knowledge, attitudes and practices regarding seasonal influenza and barriers for vaccination among nurses in Colombo. A cross sectional survey was carried out from February to March 2020 on 97 randomly selected nurses. Level of knowledge was measured using a scoring system. Only a few (n=7; 7.2%) nurses had been immunized against influenza. Overall knowledge regarding influenza and vaccines was average in most nurses (n=53; 55%). The majority (n=62; 63.9%) believed the vaccine was safe and 79.4% (n=77) were willing to be vaccinated if vaccine is provided free. However, 15 of these 77 (19.5%) were reluctant to be vaccinated annually. Identified barriers for vaccination were the perception that the vaccine was not essential, doubt about its efficacy, fear of vaccines and side effects. Knowledge should be improved, and misconceptions and fears need to be addressed through health education and promotion.


Introduction
Influenza is of public health importance as it causes epidemics and pandemics which result in three to five million severe cases and 290,000-650,000 deaths worldwide every year. 1 Respiratory illnesses are the third leading cause of hospital admissions and fourth leading cause of deaths in Sri Lanka and influenza is a major contributor. 2 Influenza vaccination decreases the risk of infection, morbidity and mortality in nosocomial infections. The vaccine is given annually and is recommended for high risk groups including health care workers (HCWs). HCWs have an occupational risk of acquiring influenza and can spread infection to patients and staff. Seasonal influenza vaccines have been approved for use but the government does not provide it free for HCWs in Sri Lanka. Vaccine coverage is reported to be low among HCWs, even in countries where it is provided free. 3 We sought to evaluate the level of knowledge, attitudes and practices (KAP) among nurses and to identify the barriers for influenza vaccination among nurses in Sri Lanka.

Methods
We conducted a cross sectional study among nurses (n=97) of a tertiary care hospital in Colombo, from February to March, 2020. A validated interviewer administered questionnaire approved by the Ethics Review Committee, Faculty of Medical Sciences, Sri Jayewardenepura, consisting of 20 open or close-ended questions was used. The questionnaire was developed in English, translated to Sinhala and Tamil and pretested in 20 participants excluded from the study. The questionnaire was administered in the preferred language of the participants. Nurses (total number in hospital 700) were recruited by systematic random sampling (sampling interval of 3.52), following informed written consent. The targeted sample size was 199.
Questions on knowledge (n=11), attitude (n=6) and practices (n=2) were included in the questionnaire. Each correct answer scored one point and incorrect or "don't know" responses scored zero. The maximum score for knowledge was 23 and was graded as good (≥ 18 points), average (13-17 points) or poor (≤12 points) ( Table 1). Descriptive statistical analysis was performed using SPSS version 16.0 (SPSS Inc., USA).

Questions testing knowledge
Grading of scores Good Average Poor 1 Can you name 4 physical features of influenza/viral fever 4 3 ≤2 2 During which months of the year do influenza outbreaks occur 1 -0 3 Is it a mild disease or does it have complications that could lead to death?
Who is at risk of severe complications from influenza?
Can you name 3 methods to prevent getting Influenza yourself Mention 3 methods of transmission Can you name 3 measures that would prevent transmission to others Is there any medication for Influenza? 1 -0 9 What are those medications? 1 -0 10 Is there a vaccine for influenza? 1 -0 11 How often the vaccine needs to be given? 1 -0 Maximum score 23

Knowledge
Level of knowledge on symptoms was good in 68% (66/97). The majority (83.5%) were aware that influenza could lead to complications and death. Knowledge regarding high risk groups was mostly average (n=38;39.2%) (Table 2a).
Knowledge on influenza transmission was poor in most (n=52; 53.6%) but was average regarding preventive measures. Only seven (7.2%) nurses mentioned influenza vaccine for prophylaxis and only 42 (43.3%) knew that Oseltamivir was the drug of choice. The majority of the nurses (74.2%) knew that an influenza vaccine was available but only five (5.2%) knew it had to be taken annually. Overall knowledge was average in 53 (55%) and a good level of knowledge was identified only in 33 (34%) ( Table 2).

Practices
Fifty eight (59.8%) nurses claimed they would go to work despite being ill. Very few nurses (n=7; 7.2%) had been immunized for influenza (Table 2b).

Discussion
Poor knowledge regarding influenza and vaccines has been identified as a barrier for vaccination. 4 Overall knowledge regarding influenza was average in our study. Nurses were knowledgeable about symptoms, consequences of influenza and had an average understanding of the high risk groups. Failure to identify HCWs as a risk group was notable. Despite responding poorly to the question on methods of transmission, nurses had an average level of knowledge on

Table 2b. Proportion of responses to questions and grading of attitudes and practices
preventive measures. Studies have found that lack of awareness of the seriousness of influenza was a factor for low uptake of influenza vaccination. 4 This is unlikely to be a factor in our study as most nurses were aware of its consequences.
In USA and Europe, the most stated reason for refusal of vaccines was the fear of side effects. 5 However, most nurses in our study perceived the influenza vaccine as safe (63.9%) and were willing to be immunized if it was given free. Only 5.2% were aware that annual vaccination was required and when apprised, willingness to vaccinate (79.4%) decreased (69.1%) (Table 2a).
Similar to our study, a study in West Java, Indonesia reported average knowledge but positive attitudes towards vaccination among nurses. 6 Survey findings of HCWs consisting mainly of nurses from Saudi Arabia describes good knowledge and attitudes, probably resulting in high level of acceptance and uptake of the vaccine. 7 Barriers for vaccination identified in our study were, the need for annual vaccination, belief that it was not essential, low efficacy, fear of vaccines and side effects. Similar to our study, poor perception of the usefulness of influenza vaccine has been consistently identified as a significant barrier to vaccine uptake in other surveys. 4 Belief that risk of acquiring disease and severity of disease was low were other identified factors, but was not observed in our study. 4 Fear of vaccine side effects were observed in both ours and previous studies. 4 We did not look for associations as very few nurses had been immunized. Studies have shown that socio-demographic factors are inconsistent predictors of vaccine intent. 4 Most nurses in our study (59.8%) did not consider influenza an illness that warranted staying away from work, as reported previously. 8 Very few (7.2%) being immunized may be due to the vaccine not being provided free and not being mandatory in Sri Lanka. Similar low immunization rates (7%) were found in Turkey, despite recommendations for regular vaccination and provision of vaccine free of charge. 9 Due to the mandatory vaccination policies in the USA, immunization rates of HCWs reached 75.2% in 2013-2014. 10 However, whether vaccination should be compulsory for HCWs is debatable.

Conclusions
Overall knowledge, attitudes and practices regarding influenza and vaccine needs to be improved in nurses. Misconceptions and fears need to be addressed if immunization programs are to be successful.

Limitations
Due to the country lockdown in March, data collection was interrupted and only 97 of the planned 199 participants could be recruited. Small sample size and very few nurses being immunized for influenza prevented us from looking for associations that affect vaccine intent. The duration of service and service in medical wards was not evaluated in this study.

Conflict of interest:
There are no conflicts of interest