THE VAXED PROJECT: An Assessment of Immunization Education in Canadian Health Professional Programs

Vaccines are undeniably one of the most important health advances of the past century. Despite proven impact on human health and longevity, many vaccines are under-utilized. The literature has clearly documented low levels of compliance with established immunization guidelines in a variety of settings [1–3]. Reasons for sub-optimal compliance and "missed-opportunities" are multi-factorial. Public and provider confidence in vaccine efficacy, concern about potential side-effects, and lack of knowledge about vaccine contraindications are common reasons for non-compliance and have been shown to contribute to lower immunization coverage in both adult and pediatric populations [4–8]. Low rates of influenza vaccination have also been reported in health care workers. In 2007-2008 only 54% of direct care providers and 37% of support staff in acute care facilities in Nova Scotia received influenza vaccination; this rate is similar to published rates for providers in the United States and Canada [9–11].

The public views health care providers as credible and trusted sources of vaccine recommendations. Many individuals cite the recommendation of their physician or nurse as the most important factor governing their decision to either become vaccinated themselves, or have their child vaccinated, and positive attitudes of health professionals have been shown to correlate with higher vaccination coverage rates [7, 12]. Despite the importance of provider endorsement and advice regarding vaccines, many healthcare providers report discomfort discussing misconceptions about adverse events following immunization with their patients and admit to being unsure about the relationship between vaccines and certain chronic diseases [13, 14].

To our knowledge no studies have examined the provision of immunization-related education during health care professional training in Canada nor the knowledge, attitudes, beliefs and behaviors of trainees graduating from Canadian health professional programs. In this study we undertook a comprehensive assessment of the needs of healthcare professional trainees regarding formal immunization education. This needs assessment will form the platform upon which to develop multi-faceted, evaluable, interprofessional educational interventions, which can be integrated into formal education curricula.

This study was approved by the Ethics Review committees of the IWK Health Centre, Capital Health, Dalhousie University, and St. Francis Xavier University.

A Canadian survey regarding preventative vaccines carried out in 2002 indicates that although support of vaccines among Canadians is broad, it is not very robust [12]. Concerns about vaccine safety in general (56%) and especially safety of new vaccines (43%) were quite broadly distributed. Another study indicated that attitudes, beliefs, and behaviours regarding vaccine safety concerns contribute substantially to under-immunization in the US [3]. It was shown that concerns were increasing amongst both parents of under-immunized and fully immunized children, as well as providers, suggesting the potential for further decreased coverage and an increase in disease outbreaks.

It is important therefore that providers are aware of immunization guidelines and vaccine safety issues, both real and perceived, and are able to communicate this information to patients and parents. Although knowledge and attitudes of health care providers have a significant impact on the frequency with which vaccines are offered and accepted, many health care providers are ill-equipped to make educated recommendations to their patients about the merits and risks of vaccines [7]. Possible reasons for this, as identified in the present survey, could be the lack of consistency in immunization education across Canada and significant gaps in knowledge coupled with worrisome attitudes regarding immunization among health professional trainees.

The national curriculum review demonstrated a wide degree of variation between health professional schools not only in the immunization-related content provided but also the amount of time allocated to immunization-related content, teaching methods used to deliver the content, and the degree to which students' knowledge of immunization content was evaluated. This variation existed between disciplines, as expected, but there was also considerable variation between programs of the same discipline. This lack of standardization results in variability in the quality of immunization education being received by health professional trainees. This is not a problem unique to Canada as similar results were reported in US-based studies [16, 17].

Limitations of this study were identified. First, immunization-related content in most schools is scattered throughout the curriculum with little apparent communication or coordination, making the review challenging. Second, hardcopies of specific learning objectives and test questions were not obtained, potentially leading to an overestimation of what was taught. Finally, the low response rate, particularly from medical schools makes it likely that the selection bias limits the generalizeability of our conclusions and it is likely that our results may actually overestimate immunization curriculum content in health professional schools due to self- selection bias by schools with more extensive immunization-related curricula.

The VaxEd survey reflected the current curriculum delivered to graduating health professional trainees in nursing, medicine, and pharmacy. This revealed important insight into deficits in knowledge and worrisome attitudes and behaviours regarding immunization. These gaps in knowledge are concerning as they are not without precedent. In previous studies, physicians reported discomfort discussing misconceptions about adverse events following immunization with patients and many admitted to not being sure about the relationship between vaccines and chronic diseases [13, 14]. This suggests that discomfort with immunization is an issue that is relevant at both a trainee and practicing level. Interestingly, 58% of students reported feeling that they had not received adequate training regarding immunization. This indicates that respondents had at least a degree of insight into the gaps in their own knowledge regarding immunization.

In summary, despite the tremendous importance of physicians, nurses, and pharmacists in ensuring optimal delivery of immunization to Canadians, review of the curricula of undergraduate training programs revealed wide variability in immunization curriculum content and evaluation. This was reflected in the important knowledge gaps identified among trainees regarding vaccine indications/contraindications, adverse events, and safety and in the lack of satisfaction with immunization-related training reported by the majority of graduates.

Development and evaluation of a competency-based interprofessional immunization education program which could be adapted and integrated into formal educational curricula would contribute significantly to health professional training programs in Canada. The Immunization Competencies for Healthcare Professionals recently developed by the Professional Education Working Group of the Canadian Immunization Committee could provide a framework for use by educators to develop and evaluate immunization educational programs adapted to the needs of health professional trainees [18].