HPV Vaccination Attitudes and Behaviors among General Practitioners in Italy

The effect of participatory action research on HPV primary preventive measures among in-school adolescents in Benue State, Nigeria

BACKGROUND

Individuals with a higher level of awareness and knowledge of HPV are more likely to dispel misconceptions about HPV and reduce their likelihood of engaging in risky sexual behavior. Behavioural change can be achieved through interventions such as participatory action research (PAR), which has been applied in various contexts. Few studies have reported on the use of PAR in Nigeria. This study aims to utilise PAR as an intervention to increase HPV awareness, improve knowledge of HPV infection, and promote behavioural change for HPV prevention among young adolescents in Benue State, Nigeria.

METHODS

The study design uses a school-based, pre-post intervention approach with a cross-sectional component. Study participants are young adolescents aged 10-19 years in selected co-educational secondary schools in three local government areas (LGAs) spread across the three senatorial zones in Benue State, Nigeria. Two-stage sampling was used to select the LGAs and schools, and the sample size was computed using the before and after implementation with some prior information from a previous study. Data on sociodemographic characteristics, HPV awareness and knowledge of infection and prevention, prevention practices, and willingness for HPV vaccination were obtained with a self-administered semi-structured questionnaire adapted from the Vaccination and HPV Knowledge (THinK) survey. The HPV Knowledge survey (New Zealand) was utilized to collect information from students at baseline and post-implementation after PAR intervention. The Wilcoxon Signed Test (WST) was used to investigate the significance of the median differences before and after the intervention. A p-value less than 0.05 or 0.001 was considered significant.

RESULTS

A total of 548 adolescents were sampled before the intervention. After the intervention, the sample size decreased to 503, reflecting an 8% attrition rate. PAR effectively increased HPV awareness among the participants from 80.9% before the intervention to 99.8% afterward. The PAR led to a significant change in knowledge of HPV infection and primary prevention and an increase in perception of HPV primary prevention. decrease in misconceptions and risky sexual behaviours, increase in HIV screening tests, and increase in the willingness of participants to uptake the HPV vaccine. Among the measures of risky sexual behaviours was a decreased perception that having more than one sexual partner is not a risk factor for HPV after the PAR intervention. The number of participants in sexual relationships decreased from 84 (16.7%) at baseline to 37 (7.4%) post-implementation. The PAR also led to a decrease in the number of participants who reported having STDs. The Wilcoxon Signed test was further disaggregated based on sex (male and female), school funding type (public and private), and school class level (junior and senior).

CONCLUSIONS

PAR led to a significant increase in awareness and knowledge of HPV, knowledge of different aspects of HPV infection, and willingness to uptake the HPV vaccine. Additionally, the study has provided evidence that PAR interventions can be a viable tool in delaying sexual initiation and reducing sexual behavioural tendencies, especially in high-risk groups.

Practices of French General Practitioners Regarding Vaccination of Boys Against Human Papillomavirus (HPV), One Year After the Application of Its Official Recommendation

In 2019, French health authorities extended the recommendation for human papillomavirus (HPV) vaccination to include boys aged 11 to 19 years. We describe HPV vaccination practices among French general practitioners (GPs) since this recommendation wasapplied. We also identified factors associated with the propensity to propose HPV vaccination to boys. Cross-sectional study, between May and August 2022, among French GPs using a questionnaire asking about the GPs, their practices, and opinions regarding HPV vaccination, including whether they systematically proposed HPV vaccination to eligible boys or not. We investigated factors associated with systematic proposal of HPV vaccination, using univariate and multivariate logistic regression. In total, 360 GPs participated (76.6% females; mean age 34.7 ± 7.8 years; 22.9% had additional training in gynecology or pediatrics); 5.5% reported that they systematically offered HPV vaccination to boys prior to the recommendation, whereas 61.2% do so systematically since the recommendation. Factors associated with systematic proposal to boys (post recommendation) were female GP sex (78.6% versus 66.2%; OR = 2.0 [95% confidence interval (CI) 1.2-3.3]; p = 0.007) and systematic proposal prior to the recommendation (8.5% versus 0.7%; OR = 13.3 [1.7-101.7]; p = 0.01). Protection against HPV-induced cancer was cited as an argument to vaccinate girls (98.3% versus 89.2%; p < 0.0001); while reducing the risk of transmission was more commonly an argument to vaccinate boys (78.1% versus 51.8%; p < 0.0001). This study underlines the positive impact of the official recommendation for HPV vaccination of boys on the attitude of GPs, with an increase in the systematic proposal of HPV vaccination to boys.

Human Papilloma Virus Infection and Vaccine Knowledge Levels, Attitudes, Beliefs in University Students: Turkey and Ghana Comparison

Purpose: Studies reported that early diagnosis, treatment, and prevention of cervical cancer are influenced by knowledge, beliefs, and attitude toward screening. This descriptive-comparative study aimed to assess human papilloma virus (HPV) knowledge, attitudes, and beliefs in university students and the affecting factors and to compare between Turkish and Ghanaian students. Methods: The sample consists of 933 university students studying in 4 different faculties in 2 universities from Turkey and Ghana. The data were collected between November 2019 and February 2020. The study's data were analyzed using Analysis of Variance, Pearson Correlation test, t-test, and Mann-Whitney U test. Results: The findings of the study showed that none of the students in both countries had HPV vaccination. It was found that students have low level of knowledge about HPV infection and vaccine (3.28 ± 2.14) and positive attitudes (16.57 ± 3.28) and beliefs (36.74 ± 6.55) toward vaccine. The attitude score of the Ghanaian students (17.54 ± 3.23) was found to be significantly higher than the Turkish students (15.74 ± 3.09). The knowledge score of the Ghanaian students who had sexual intercourse was found to be significantly higher than others. The findings of the study revealed that the students of both countries had low level of knowledge about HPV infection and vaccine and positive attitudes and beliefs toward the vaccine. Conclusions: It is recommended to increase effective interventions to increase the knowledge level of university students about HPV infection and vaccine. In addition, the vaccine should be included in the immunization program in both countries.

Evaluating Knowledge, Attitudes, and Behaviors toward HPV Infection and Vaccination among University Students in Italy

BACKGROUND

This survey investigated the knowledge, attitudes, and behaviors towards HPV preventive measures among university students in Italy and their associated factors.

METHODS

The cross-sectional survey was conducted between November 2022 and April 2023.

RESULTS

Only 41.7% knew about HPV infection and the main preventive measures. Multilevel mixed-effects logistic regression analysis showed that females, those aged 25-30 years, those who have had oral sex, those who had received information about HPV infection and preventive measures from physicians, and those who needed additional information about HPV infection and preventive measures were more knowledgeable. Only 39.1% have received at least one HPV vaccination dose, whereas 29.2% and 31.7% had not been vaccinated or did not remember. Multilevel mixed-effects logistic regression analysis identified that female students enrolled in the field of health sciences, those who did not report a prior history of a sexually transmitted infection, and those with a higher knowledge about HPV infection and preventive measures were more willing to receive the HPV vaccination.

CONCLUSIONS

Despite some limitations, this was the first detailed survey on this topic conducted in the post-acute phase of COVID-19 among university students in Italy. The survey underlined the need to develop and to implement comprehensive educational programs and health interventions among students, to enhance their knowledge and modify their attitudes and improve the HPV vaccine uptake.

Cancers attributable to infectious agents in Italy

OBJECTIVES

To provide an evidence-based, comprehensive assessment of the current burden of infection-related cancers in Italy.

METHODS

We calculated the proportion of cancers attributable to infectious agents (Helicobacter pylori [Hp]; hepatitis B virus [HBV] and hepatitis C virus [HCV]; human papillomavirus [HPV]; human herpesvirus-8 [HHV8]; Epstein-Barr virus [EBV]; and human immunodeficiency virus [HIV]) to estimate the burden of infection-related cancer incidence (2020) and mortality (2017). Data on the prevalence of infections were derived from cross-sectional surveys of the Italian population, and relative risks from meta-analyses and large-scale studies. Attributable fractions were calculated based on the counterfactual scenario of a lack of infection.

RESULTS

We estimated that 7.6% of total cancer deaths in 2017 were attributable to infections, with a higher proportion in men (8.1%) than in women (6.9%). The corresponding figures for incident cases were 6.5%, 6.9% and 6.1%. Hp was the first cause of infection-related cancer deaths (3.3% of the total), followed by HCV (1.8%), HIV (1.1%), HBV (0.9%), HPV, EBV and HHV8 (each ≤0.7%). Regarding incidence, 2.4% of the new cancer cases were due to Hp, 1.3% due to HCV, 1.2% due to HIV, 1.0% due to HPV, 0.6% due to HBV and <0.5% due to EBV and HHV8.

CONCLUSIONS

Our estimate of 7.6% of cancer deaths and 6.9% of incident cases that were attributable to infections in Italy is higher than those estimated in other developed countries. Hp is the major cause of infection-related cancer in Italy. Prevention, screening and treatment policies are needed to control these cancers, which are largely avoidable.

Family physicians' practices and attitudes towards HPV vaccination since extension of HPV vaccination to males

OBJECTIVES

To describe family physicians' (FP) practices and attitudes towards HPV vaccination guidelines since its extension to males in 2021, and to identify levers to promote HPV vaccination in all adolescents.

PATIENTS AND METHODS

Cross-sectional study among FPs established in France in 2021. We collected sociodemographic data, practices, opinions, and attitudes towards vaccination, and FPs' demands regarding training and information about HPV. We used logistic regression models to identify the variables associated with HPV vaccination proposal.

RESULTS

Of 530 FPs included, 469 (88.5%) reported that they systematically proposed HPV vaccines to girls vs 335 (63.2%) to boys. A total of 366 (69.0%) FPs reported an increase in HPV vaccines proposal to all adolescents since the extension of HPV vaccination to males recommended by French guidelines. However, factors associated with HPV vaccination proposal differed by target females and target males. Setting and mode of practice, opinion about the number of recommended vaccines and HPV vaccines, and demands of training on HPV vaccines were associated with HPV vaccination proposal to target females. Whereas academic status, opinion about HPV vaccination guidelines extension to males, using continuing medical education as the main source of information on HPV vaccines, and demands for training on HPV vaccines were associated with HPV vaccination proposal to target males.

CONCLUSIONS

Extension of HPV vaccination to males in French guidelines might have had a favorable impact on HPV vaccination proposal by FPs to adolescents. However, levers to promote HPV vaccination might differ according to the target population sex.

Knowledge and attitudes of health care workers about monkeypox virus infection in Southern Italy

Background

This present survey sought to investigate the level of knowledge and the attitudes pertaining the monkeypox (mpox) virus infection among a sample of health care workers (HCWs) in Italy, as well as the possible role of different factors on these outcomes.

Methods

The cross-sectional survey was performed from July through October, 2022 at four randomly selected hospitals located in Southern Italy.

Results

The questionnaire was completed by 421 HCWs, for an overall 59% response rate. Less than two-thirds were able to define the disease and the correct answer of the transmission mechanisms ranged from 22.8% for contact with contaminated objects to 75.8% through close contact with body fluids. Only 4% and 12.8% indicated HCWs and elderly/frail/people with underlying immune deficiencies as risk groups. The mean overall score of the knowledge assessment on mpox was 3.4 (0-9). The multivariate logistic regression analysis showed that HCWs with a lower number of years of working experience and those who had acquired information about mpox from scientific journals were more likely to have a higher level of knowledge. The average score of the perception of the severity of the disease was 6.3. A similar score with a value of 6.1 has been observed for the statement that mpox is a serious problem for the population. Regarding the level of concern about contracting mpox, the mean score was 5.1. Only 10.5% reported that they feel that this disease can be prevented, with an overall mean score of 6.5. Almost all HCWs reported that they are still living as usual, with no modification of their behavior for fear of contracting the mpox. The results of the multivariate logistic regression model showed that women, HCWs with a higher level of knowledge about mpox, and those who needed additional information about mpox were more likely to have a higher level of perception of the severity of the disease.

Conclusion

This survey has demonstrated that HCWs had an unsatisfactory level of knowledge toward mpox and only nearly half showed positive attitudes. Strategic health training programs should be made so that knowledge can be acquired.

Understanding Primary Care Physician Vaccination Behaviour: A Systematic Review

BACKGROUND

Vaccine hesitancy decreases adult vaccination coverage and has been recognized by WHO as a major health threat. Primary care physicians (PCP) play a key role in vaccination by giving vaccine counselling to their patients. The aim of this systematic review is to identify the knowledge, beliefs, attitudes and barriers (KBAB) associated with own vaccination and patient recommendation in primary care physicians.

METHODS

MEDLINE/PubMed, EMBASE and Cochrane Library databases were used to search and identify relevant studies based on their title and abstract. In the next step, the full text of each previously selected article was read for eligibility. Articles were selected by two independent reviewers and data extraction was performed using tables. The following information was extracted: methodological characteristics, demographic factors, professional characteristics, and intrinsic or extrinsic factors influencing vaccination or recommendation.

RESULTS

Our search yielded 41 eligible papers, data-sources, previous practices, belief in the effectiveness or safety of the vaccine, perceived risk, and trust in health authorities were all shown to be related to own vaccination and patient recommendation.

CONCLUSION

Internet is the main source of information for PCP related to vaccine hesitancy. It is therefore essential to increase the presence and access to pro-vaccination content in this area. In addition, involving PCP in the establishment of vaccination recommendations could improve their credibility in the institutions. On the other hand, training in communication skills and establishing reminder systems could reflect higher vaccination coverage among their patients.

Parents' reasons to vaccinate their children aged 5–11 years against COVID-19 in Italy

Objectives

The aims of this cross-sectional study were to investigate why parents decide to vaccinate, as well as the determinants, their children aged 5–11 years against COVID-19 in Italy.

Methods

The survey was conducted from January through May 2022. All parents/guardians who came in randomly selected days to immunization centers for the administration of the first dose of the COVID-19 vaccine to their child were asked to complete a questionnaire about socio-demographic characteristics, attitudes toward COVID-19 infection and vaccination, reason(s) regarding their decision to vaccinate their child, and source(s) of information.

Results

A total of 358 questionnaires were collected. Parent's perception that COVID-19 is a severe illness for the child, assessed using a 10-point Likert scale, was 7.5. The overall mean scores of the risk perception for their child of having the COVID-19 before and after the vaccination were 8.1 and 6.3. A significantly higher parents' level of risk perception for their child of having the COVID-19 after the vaccination has been observed among those not having a university degree, those with the child having at least one chronic medical condition, and those who perceived that COVID-19 is a severe illness for the child. The mean value of respondent trust in the information provided by the pediatricians on a 10-point scale Likert type was 7.6. Female, not having a university degree, higher perception that COVID-19 is a severe disease, not having received information about the vaccination from pediatricians, and needing information had a significantly higher concern of side effects after the vaccination. The most common reasons for vaccinating their children included wanting to protect the child against COVID-19, to attend the school with less risk, to prevent the transmission to family members, and to practice sport and other activities with less risks. Participants with a university degree were more likely to have vaccinated their child for attending the school and practicing sport and other activities with less risks.

Conclusions

More publicity should be promoted among parents of children aged 5–11 years which would increase the coverage rates and thus lower the transmission of SARS-CoV-2 and reduce the occurrence of COVID-19.

Do Pediatricians and Nurses Recommend Vaccines for Preterm Infants? A Survey in Italy

OBJECTIVE

To assess the level of knowledge, attitudes, and behaviors regarding vaccination in preterm infants among primary care pediatricians (PCPs) and health care workers (HCWs) in neonatal intensive care units (NICUs).

STUDY DESIGN

Data were collected from PCPs through a confidential questionnaire distributed by email, whereas the research team distributed a self-administered anonymous questionnaire to all HCWs working in the selected NICUs.

RESULTS

Overall, 64.1% of HCWs consider vaccines in preterm infants to be very safe. The majority of HCWs (69.8%) stated that they always recommend that preterm infants' parents vaccinate their children following the same schedule as for term infants. This behavior was significantly more likely among those who know that the vaccination schedule for preterm infants is the same as for term infants, who consider vaccines in preterm infants very effective, and who strongly agree that preterm infants should be vaccinated on the same schedule as term infants. Moreover, PCPs were more likely than NICU pediatricians to always recommend that preterm infants' parents vaccinate their children following the immunization schedule of term infants, whereas this behavior was significantly less frequent among NICU nurses.

CONCLUSIONS

There is a need for physicians and nurses in the NICU and in the community to counteract missed or delayed immunizations. Engagement of HCWs in healthcare quality improvement initiatives focused on the promotion of timely vaccinations in preterm infants should be encouraged.

The Impact of COVID-19 Vaccination in Changing the Adherence to Preventive Measures: Evidence from Italy

The objectives of the survey were to explore any changes in the adherence to the three main COVID-19 preventive measures (social distancing, washing hands, wearing face-masks) among 795 individuals who received the COVID-19 vaccine booster dose in Italy and to identify the predictors associated. The concern of contracting COVID-19 before the vaccination, after the primary COVID-19 vaccine series, and after the booster dose resulted with a mean value of 7.7, 4.6, and 4.2, respectively. Females, those who had a lower mean self-perceived health status, who perceived COVID-19 as a very serious health problem, who decided to receive the booster dose because they perceived to be at risk of getting COVID-19, and who expressed interest in acquiring more information regarding the COVID-19 vaccine booster dose were more likely to report a higher concern of contracting COVID-19 after the booster dose. Over two-thirds were willing to respect the three main COVID-19 preventive measures following the booster dose. The multinomial logistic regression analysis showed that those who had used all three main preventive measures before and after the second or single dose were less likely to perceive COVID-19 as a serious illness. Those who had used them irregularly were less likely to have used official government organizations and scientific journals as sources of information. This survey provided an understanding regarding the adherence to COVID-19 preventive measures that may help to target policy interventions needed to reduce the spread of SARS-CoV-2.

Evaluating COVID-19 Vaccine Willingness and Hesitancy among Parents of Children Aged 5–11 Years with Chronic Conditions in Italy

COVID-19 vaccination has been extended to include children aged 5–11 years. This cross-sectional survey evaluated parental COVID-19 vaccine willingness and hesitancy, and associated factors, for their children aged 5–11 years with chronic conditions. A telephone survey was conducted from 14 December 2021 to 4 January 2022. The questionnaire assessed participants’ socio-demographic and health-related information, attitudes towards COVID-19 infection, hesitancy, by using the PACV-5 (Parent Attitudes About Childhood Vaccines Survey Tool), and sources of information. A total of 430 answers were collected anonymously. Respondents with no cohabitant who had been infected by SARS-CoV-2 and having been vaccinated against COVID-19 had a higher concern about the severity of COVID-19. The parents’ perceived risk that the child could be infected by SARS-CoV-2 was higher in those more concerned about the severity of COVID-19, with an older child, and who had at least one cohabitant positive for COVID-19. Only 38.8% parents were willing to vaccinate their children against COVID-19. Parents who did not need additional information, those with higher education, those who have been vaccinated against COVID-19, those whose child was older, who had received information on this vaccination from physicians, with higher self-reported concern about the severity of COVID-19, and who had a higher perceived risk that their child could be infected by SARS-CoV-2, expressed a greater willingness to vaccinate their child. Overall, 26.3% were high-hesitant, with a PACV-5 score ≥ 7. Respondents who did not get the COVID-19 vaccine, were less educated, with a lower concern about severity of COVID-19, and with a lower perceived risk that their child could be infected by SARS-CoV-2, were more likely to be high-hesitant. New policies and educational programs regarding COVID-19 vaccination for children with chronic conditions are needed to reduce hesitancy and increase vaccination uptake.

Human Papilloma Virus Vaccination: Focus on the Italian Situation

Human papilloma virus (HPV) is a viral agent whose transmission occurs mainly by sexual means. It causes different pathological conditions in both males and females, ranging from benign pathologies up to cancers. The introduction of vaccination has certainly had a major impact in terms of reducing the incidence of both HPV infections and diseases but in the European Union and the European Economic Area (EU/EEA) there are still about more than 13,000 deaths due to cervical cancer each year. To date in Europe and in Italy there are three vaccines available (bi-, tetra-, and nonvalent vaccines). The vaccination campaign started irregularly in Europe and Italy in 2007, with pre-adolescent girls as the primary target. Later, other cohorts were introduced such as 12-year-old boys, additional cohorts of >25-year-old women, women who already underwent cervical surgery and other subjects entitled to free vaccination. The COVID-19 pandemic has strongly impacted on public health services, particularly on vaccinations that, especially during the first pandemic phase, have been often delayed and/or canceled. The most affected vaccinations by the pandemic have been the non-mandatory ones, particularly those addressing the adolescent and adult population, such as immunization against papillomavirus. To date the achievement of the coverage target set by the Italian National Immunization Plan (NIP) has not yet been achieved. The aim of this work is to summarize the current situation in Italy and to discuss the strategies that have been implemented to increase overall vaccination coverage rates.

Changes in Behaviors and Attitudes in Response to COVID-19 Pandemic and Vaccination in Healthcare Workers and University Students in Italy

The objectives of the cross-sectional study were to measure how behaviors and attitudes about preventive measures toward COVID-19 changed over time among Italian vaccinated healthcare workers and university students, and the associated characteristics. The study was carried out between February and March 2021 in the city of Naples, Campania region, Southern Italy. The perceived personal risk of being infected by SARS-CoV-2 after the vaccination was significantly higher among males, in those having a higher perceived personal risk of being infected by SARS-CoV-2 before the vaccination, and in those who were more concerned about the efficacy of the vaccination. The fear of getting the disease as reason to have the COVID-19 vaccination was reported more frequently in younger participants, in those with at least one chronic medical condition, in those with a higher concern about the severity of COVID-19, in those with a higher level of trust in the information received, and in those who acquired information from scientific journals. Overall, 21.3% were willing to engage the three main public health measures (wearing a mask, careful hand washing, physical distancing) after receiving the second dose of the vaccination compared to the behavior before the pandemic began. This willingness was predicted by a higher level of trust in the information received and by a lower self-rated health status. Only 0.1% of participants were willing to engage all three measures after receiving the second dose of the vaccination compared to the behavior before receiving the first dose. These findings are useful in order to develop information strategies regarding vaccine safety and efficacy and the importance of public health measures against COVID-19.

Characteristics of Healthcare Workers Vaccinated against Influenza in the Era of COVID-19

Understanding the potential impact of COVID-19 on receiving influenza vaccination among healthcare workers (HCWs) is of utmost importance. The purposes of the present cross-sectional study were to describe the characteristics and to explore the predictors of receiving influenza vaccination among a large cohort of Italian HCWs in hospital settings. Information was collected through an anonymous questionnaire from December 2020 through January 2021. General and practice characteristics, perceived risk of seasonal influenza, attitudes towards efficacy and safety of influenza vaccination, and reasons behind the decision to be vaccinated against influenza were explored. Fewer than half (46.2%) of HCWs agreed that influenza is a serious illness and perceived the risk of getting infected with influenza, and concerns about the safety of the vaccination were significant positive predictors. Fewer than half of the respondents were not concerned at all about the efficacy (48.6%) and safety (49.8%) of influenza vaccination, and 51.9% reported that they have not received a seasonal influenza vaccine during the previous season. The most mentioned reason for receiving the influenza vaccine in the current season was that influenza and COVID-19 share some similar symptoms. Study results will aid policymakers in developing vaccination education programs, promotion of trust to address negative misconceptions, and to achieve future high coverage among this high-risk group.

What Prompts Doctors to Recommend COVID-19 Vaccines: Is It a Question of Positive Emotion?

Vaccines are among the most successful and cost-effective public health tools and have greatly contributed to eliminating or controlling several serious vaccine-treatable diseases over the past century. To curb the spread of COVID-19, efficacious vaccination is emerging as essential in mitigating the disease and preventing deaths. Health care workers (HCW) are one of the first groups to receive vaccinations, so it is important to consider their attitudes to COVID-19 vaccination to better address barriers to widespread vaccination acceptance. This study aimed to evaluate variables that are linked with the recommendation of vaccines and intention to take-up vaccination against COVID-19 among the HCWs, in the context of the current pandemic. The study was conducted during the first week of the vaccination campaign dedicated to Italian HCWs, beginning in December 2020, and it involved all doctors in a public hospital in Sicily. The following questionnaires were administered: (1) The perceived vaccine trust questionnaire, measuring the degree of trust in vaccines by healthcare professionals both in general and for the protection of healthcare professionals themselves and patients; (2) the positive and negative affect scale-state (PANAS), for assessing positive and negative emotions in relation to their work as “frontline care providers”; (3) The locus of control of behaviour (LCB) to measure the extent to which subjects perceive responsibility for their personal behaviour (internal vs. external); (4) recommendation vaccines item, referring to the intention to recommend vaccination. The findings suggest that socio-demographic control variables (age, gender, and seniority) showed little or no predictive power in vaccine recommendation, while vaccine confidence, positive emotions, and internal locus of control were excellent predictors of vaccine recommendations by doctors. Younger doctors, both in age and experience, are more confident in vaccines and recommend them more frequently. It is essential to improve institutional communication addressed to doctors to enhance their role as vaccination facilitators.