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Vaccine 25 (2007) 1669–1675

A survey of knowledge, attitudes, and behavior ofItalian dentists toward immunization

Gabriella Di Giuseppe a, Carmelo G.A. Nobile a,Paolo Marinelli b, Italo F. Angelillo b,∗

a Chair of Hygiene, Medical School, University of Catanzaro “Magna Græcia”, Catanzaro, Italyb Department of Public, Clinical and Preventive Medicine, Second University of Naples,

Via Luciano Armanni, 5, 80138 Naples, Italy

Received 1 August 2006; received in revised form 12 October 2006; accepted 31 October 2006Available online 10 November 2006

bstract

This study assessed the knowledge, attitude, and compliance to immunization guidelines among dental health-care professionals in Italy. Auestionnaire was mailed to a random sample of 1000 dentists on demographic and professional characteristics; knowledge regarding infectiousiseases that can be acquired/transmitted by the dentist and the vaccinations recommended; attitudes regarding the vaccinations; self-assessednformation about previous vaccinations. A total of 369 dentists responded. Only 44.1 and 32.4% correctly indicated all infections that cane acquired or transmitted during their activity. Half of the dentists knew that they should be vaccinated against hepatitis B and influenza andhis knowledge was significantly higher in those older, who correctly indicated that hepatitis B and influenza can be acquired and transmitteduring their activity, and in those with a positive attitude towards vaccinations. Those younger, involved in specialties with low blood contact,nd who did not know that hepatitis B and influenza are vaccinations recommended, were more likely to believe that is important for themo receive vaccinations. A large proportion (85.7%) reported receiving the hepatitis B vaccine, but only 56.2% the three doses. Those with a

ower number of years of activity, those who knew that hepatitis B can be acquired by the dentist, those who did not need information, andhose who were informed from guidelines, educational courses, and dental associations were more likely to have received the three doses oro be natural immunizated. Training and educational interventions are needed to improve knowledge and immunization coverage.

2006 Elsevier Ltd. All rights reserved.

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eywords: Attitude; Behavior; Dentists; Knowledge; Italy; Vaccination

. Introduction

Health-care workers are at risk for blood-borne, airborne,nd droplet-spread transmission of infectious agents becausef their frequent and often intensive occupational exposureshat include percutaneous injury, contact of mucous mem-rane or non-intact skin with blood or other body fluids thatre potentially infectious. They may also act as potentialectors for nosocomial transmission of several infections to

atients and other close contacts. In Italy, the number of casesf hepatitis B reported in the 2004 was 1171; whereas, the

∗ Corresponding author. Tel.: +39 081 5666031; fax: +39 081 459517.E-mail address: italof.angelillo@unina2.it (I.F. Angelillo).

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umber for the other infectious diseases ranged from 461 forubella to over 125,000 for varicella [1].

It has been widely recognized and documented in theiterature that the use of specific standard precautions and pro-ective equipment is designed to decrease the risk of acquiringr transmitting occupational infections in the health-care set-ings. In particular, the most efficient method of preventingeveral hospital-acquired infections and resulting morbiditynd mortality is by the use of pre-exposure immunization.oreover, it is now undeniable that vaccination of health-careorkers does result in improved patient and employee safety

nd, therefore, immunizations are strongly recommendedgainst several diseases for health-care personnel [2,3].

Evidence-based expert recommendations have shown thatersonal and organizational characteristics influence accep-

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670 G. Di Giuseppe et al. /

ance of vaccination and determine its success and, therefore,t is important to understand the knowledge of health-are providers and their behavior concerning immunizations.lthough several investigations have examined vaccination

n health-care workers mainly for influenza [4–6], to theest of our knowledge there are limited survey type ques-ionnaires to evaluate dental health-care workers’ opinions,nowledge, and the degree to which they have adhered toecommendations for the use of vaccines into their regularractice [7–10]. Since a wide range of microorganisms posethreat in the dental setting, information on this topic isarranted to overcome practice-level barriers aimed at pre-enting occupational-associated transmission of infectiousgents. Therefore, the purpose of this population-based studyas to extend previous research by assessing the level and

he effect of different variables on knowledge, attitude, andompliance to guidelines pertaining to immunization amongental health-care professionals in Italy.

. Materials and methods

This cross-sectional investigation, which took placeetween September 2005 and June 2006, was conductedmong a random sample of 1000 dentists drawn from randomists of members of the Italian Board of Dentists (memberships mandatory for licensure in Italy).

A self-administered anonymous questionnaire was mailedo the selected participants, with an accompanying coveretter providing details on the purpose of the study and reas-uring dentists of their anonymity, and a reply-paid addressednvelope. To keep track of dentists who responded and todentify those who required follow-up, each returned enve-ope was individually coded with an identification number,nown only to the research team. To encourage participa-ion of those dentists who did not respond to the initial

ailed questionnaire, in order to increase the response rate,elephone calls and two additional complete mailings, withnother copy of the questionnaire and of the envelope, wereent to the non-respondents. After the third mailing, the iden-ifying key was destroyed, thus maintaining total anonymityf all respondents. A total of 168 dentists could not be con-acted by telephone because their numbers were not available.nformed written consent was obtained from all participantsrior to entry into the study and confidentiality was assured.ll interviews were voluntary and in the accompanying cover

etter all potential participants were advised that they had theight to comply or decline participation.

The survey consisted of a series of questions assess-ng demographic and professional characteristics; knowledgeegarding infectious diseases that can be acquired/transmittedy the dentist and recommended vaccinations for the dentist;

ttitudes regarding the vaccinations; self-assessed informa-ion about own vaccinations status; and the sources used tobtain information about vaccines and how effective theyonsider these sources. The demographic and professional

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25 (2007) 1669–1675

ection of the instrument included questions on age, gen-er, practice setting, specialty, number of years in clinicalractice, number of hours spent in a week in direct patientare, and number of patients seen in a workday. The knowl-dge was measured using a set of questions and all responsesere of the “yes/no/do not know” format. Attitudes were

ssessed with a series of statements relating to “key immu-ization beliefs” using a 3-point Likert-type scale evaluationsf agreement or disagreement. The attitude on the utility ofaccinations for the dentist was measured on a 10-point Lik-rt scale with options ranging from “1” (low utility) to “10”high utility). The questions addressing hepatitis B, influenza,easles, mumps, rubella, and varicella-zoster immunizations

omprised questions regarding the number of doses receivedf each vaccine and the year of last dose. Those who haveeceived immunizations or have not, were asked to indicate,ith an open option always allowed, the reason(s) for accept-

ng or refusing vaccination.The original version of the questionnaire was pilot tested,

ith subjects who were similar in their characteristics to theembers of the study population, in order to ensure practica-

ility, validity, and interpretation of answers. On the basis ofhe comments and suggestions obtained from the pilot study,he questionnaire was revised before distribution to the studyample. Instrument revision included changes to question-aire item wording and format only if there was near universalonsensus on their meaning.

.1. Statistical analysis

Multivariable stepwise logistic and linear regression anal-ses were employed to examine the association of the variousredictors with each of the following outcomes of inter-st: knowledge that vaccinations against hepatitis B andnfluenza are recommended for the dentist (model 1), com-leting with three doses the vaccination against hepatitis B oreported acquired natural immunity (model 2), positive atti-ude towards the utility of vaccinations for the dentist (model). The following independent variables that were consid-red potentially associated with the outcomes were includedn all models: gender (male = 0, female = 1), age (continu-us), primary practice setting (private = 0, other = 1), dentistpecialty (low probability of blood contact = 0, high prob-bility of blood contact = 1), number of years in practicecontinuous), number of hours worked per week (continu-us), number of patients seen in a workday (continuous),uidelines, educational courses, and dental associations asource of information about vaccinations (no = 0, yes = 1),nd the need of additional information about vaccinationsno = 0, yes = 1). In model 1, the variables knowledge thatepatitis B and influenza can be acquired and transmitted byhe dentist (no = 0, yes = 1) and positive attitude that is impor-

ant for the dentist receive vaccinations against hepatitis Bnd influenza and that these vaccinations are not dangerousno = 0, yes = 1) were also included. In model 2, the variablesnowledge that hepatitis B can be acquired and transmitted

Vaccine 25 (2007) 1669–1675 1671

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Table 1Main characteristics of the responding dentists

Characteristic N % Mean ± S.D.

GenderMale 272 73.7Female 97 26.3

Age group (years) 43.6 ± 10.1≤30 34 9.231–35 51 13.836–40 69 18.741–45 66 17.946–50 56 15.2>50 93 25.2

Specialtya

Restorative dentistry 221 59.9Endodontics 180 48.8Prosthetics 134 36.3Periodontics 93 25.2Orthodontics 85 23Oral surgery 83 22.5Implantology 78 21.1

Primary practice typePrivate 320 86.7Other 49 13.3

Number of years in practice 15.1 ± 8.5≤10 116 31.411–15 89 24.116–20 85 23.1>20 79 21.4

Number of hours worked for week 32.5 ± 9.7≤30 152 41.231–40 171 46.3>40 46 12.5

Number of patients seen in a workday 10.3 ± 5.1<5 51 13.85–10 211 57.211–15 75 20.3

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y the dentist (no = 0, yes = 1), knowledge that hepatitis Baccination is recommended for the dentist (no = 0, yes = 1),ositive attitude that is important for the dentist receive vac-ination against hepatitis B and that this vaccination is notangerous (no = 0, yes = 1), and the routine use of all barrierechniques (no = 0, yes = 1) were also included. In model 3,he variables knowledge that hepatitis B, influenza, measles,

umps, rubella, and varicella-zoster can be acquired andransmitted by the dentist (no = 0, yes = 1) and knowledgehat hepatitis B, influenza, measles, mumps, rubella, andaricella-zoster vaccinations are recommended for the dentistno = 0, yes = 1) were also included. Variables associated withach outcome of interest at a screening level of significanceith p-value ≤0.25 in the univariate analysis were included

n the logistic and linear regression models to determine mul-ivariate significance. We next set the significance level forariables entering in the multivariate logistic regression mod-ls at p = 0.2 and for removing from the model at p = 0.4.ssociation between the characteristics and outcomes was

xpressed as odds ratios (ORs) and 95% confidence inter-als (CIs) of the adjusted ORs. All hypothesis tests werewo-tailed and p-values ≤0.05 were considered to be statisti-ally significant. All analyses were done using the statisticalackage Stata [11].

. Results

Of the 1000 selected dentists approached in the study,9 were ineligible because they were no practicing dentalare and 15 were returned because of incorrect addresses.here were 369 questionnaires returned, yielding an over-ll response rate of 40.3%. Table 1 presents the distributionf demographic and practice characteristics of the sample.ore than two-third were males, the average age was 43.6

ears (range 25–81), the vast majority was in private practicenly, and they represented a broad range of years in practice,ours spent in a week in direct patient care, and workdayatients’ volume. Because no statistically significant differ-nces in demographics and practices characteristics betweenarticipating and non-participating dentists were observed,e believe that the two groups were comparable.The majority of those surveyed correctly identified that the

epatitis B and influenza can be acquired or transmitted byhe dentist during the working activity, whereas many dentistshowed lack of knowledge with the percentages of correctnswers for almost all other infections below 50%. Only 44.1nd 32.4% of respondents correctly indicated all infectionshat can be acquired or transmitted during their working activ-ty, respectively. Vaccines, with the exception of hepatitis B97.3%), were identified to be recommended for the dentistith values ranging from 56.6% for influenza to 13.8% for

aricella-zoster. Half of the respondents knew that dentistshould be vaccinated to prevent hepatitis B and influenza55.3%) and, in the multivariate logistic regression model,hree correlates achieved statistically significant association

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elected more than one specialty.

ith this knowledge. Indeed, knowledge was significantlyigher in older dentists (OR = 1.05; 95% CI 1.02–1.08), inhose who correctly indicated that hepatitis B and influenzaan be acquired and transmitted during the working activityOR = 4.37; 95% CI 2.61–7.33), and in those with a positivettitude towards vaccinations (OR = 6.04; 95% CI 3.67–9.94)model 1 in Table 2).

Respondents were asked about the importance of certainspects of vaccination and the responses can be viewed inable 3. Almost all (95.7%) agreed with the statement that

t is important for the dentist receive vaccination againstepatitis B; whereas, the levels of agreement for the other vac-inations were considerably lower ranging from 59.9% fornfluenza and 16% for varicella-zoster. There was no varia-

ion in vaccine-specific positive attitude about safety, becausevery small percentage though that immunization was unsafer dangerous, although for the majority of vaccines almostne-third of respondents was uncertain with these beliefs.

1672 G. Di Giuseppe et al. / Vaccine 25 (2007) 1669–1675

Table 2Logistic (1–2) and linear (3) regression models results

Variable OR S.E.a 95% CI p-Value

Model 1: Knowledge that vaccinations against hepatitis B andinfluenza are recommended for the dentist.Log-likelihood = −200.15, χ2 = 107.12 (4 d.f.), p < 0.0001Positive attitude that is important for the dentist receive

vaccinations against hepatitis B and influenza and that thevaccinations are not dangerous

6.04 1.54 3.67–9.94 <0.0001

Knowledge that hepatitis B and influenza can be acquiredand transmitted by the dentist

4.37 1.15 2.61–7.33 <0.0001

Age 1.05 0.01 1.02–1.08 <0.0001Number of hours worked per week 1.02 0.01 0.99–1.04 0.19

Model 2: Completing with three doses the vaccination againsthepatitis B or reported acquired natural immunity.Log-likelihood = −233.99, χ2 = 38.15 (6 d.f.), p < 0.0001Guidelines, educational courses, and dental associations as

source of information about vaccinations2.01 0.46 1.28–3.16 0.003

Number of years in practice 0.92 0.03 0.87–0.97 0.003Knowledge that hepatitis B can be acquired by the dentist 5.29 3.74 1.32–21.14 0.018Need of additional information 0.53 0.16 0.29–0.96 0.037Number of hours worked per week 1.02 0.01 0.99–1.04 0.11Age 1.03 0.25 0.98–1.08 0.13

Variable Coefficient S.E.a t p-Value

Model 3: Positive attitude towards the utility of vaccinations for thedentist. F(4,361) = 5.98, p = 0.0001, R2 = 62.1%, adjusted R2 = 51.7%Dentist specialty 0.54 0.21 2.62 0.009Knowledge that hepatitis B, influenza, measles, mumps, rubella, and

varicella-zoster can be acquired and transmitted by the dentist−0.92 0.37 −2.49 0.013

Age −0.02 0.1 −2.26 0.024

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he mean score of respondents’ beliefs towards the useful-ess of vaccinations for preventing infectious diseases wasenerally high, with a score of 8.5, indicating a very favor-ble attitude. Results of the multivariate linear regressionodel indicated that being younger, involved in specialtiesith low blood contact, and not knowing that vaccinations

gainst hepatitis B, influenza, measles, mumps, rubella, andaricella-zoster are recommended were significantly associ-ted with greater belief that it is important for the dentists toeceive vaccinations (model 3 in Table 2).

A total of 85.7% dentists reported that they had beenaccinated against hepatitis B, 4.6% had a history of infec-ion, 3.5% did not remember their history, and 6.2% didot receive the vaccine. Among those immunized, 56.2%

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able 3espondents’ attitudes towards the vaccinations

A dentist should be immunized against

Agree (%) Uncertain (%) Disagree (

epatitis B 95.7 1.9 2.4nfluenza 59.9 20.6 19.5

easles 19.8 33.1 47.1umps 21.7 34.7 43.6ubella 21.4 34.7 43.9aricella-zoster 16 33.9 50.1

0.27 0.26 1.05 0.299.07

eported receiving a complete scheme consisting of threeoses, whereas 11.9% received an incomplete vaccinationone or two doses), 28% received it but did not indicate theumber of doses. Multiple logistic regression was performedo test for the independent association between several vari-bles and having completed with three doses the hepatitis Baccination or having acquired natural immunity. Respon-ents with a lower number of years of activity (OR = 0.92;5% CI 0.87–0.97), those who knew that hepatitis B cane acquired by the dentist (OR = 5.29; 95% CI 1.32–21.14),

hose who did not need additional information (OR = 0.53;5% CI 0.29–0.96), and those who received informationbout vaccination from guidelines, educational courses, andental associations (OR = 2.01; 95% CI 1.28–3.16) were

Vaccination is dangerous

%) Agree (%) Uncertain (%) Disagree (%)

4.3 15.5 80.23 17.9 79.14.3 35 60.74.3 34.7 614.6 35.5 59.94.6 39.8 55.6

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ore likely to have completed with three doses the hepatitisvaccination or have acquired natural immunity (model 2 in

able 2). Approximately one-third (33%) of the participantsndicated that they had been vaccinated in the previous yeargainst influenza; for the other recommended vaccinationshe vast majority responded that they were seropositive fromatural infection and the prevalence of unvaccinated dentistsanged from 32.9% for measles to 43.9% for rubella. Over-ll, 81.6% of the sample have received all six vaccinations orave acquired a natural immunity.

Dentists were asked to report the reasons for their partici-ation or non-participation in hepatitis B and annual influenzaaccinations programs. Among those who were immunizedgainst both infections, the most common reason was thathey believe that vaccine prevents the onset of disease or itsomplications (68.5 and 87.9%, respectively), that hepatitisis a serious disease (47.4%), and that the vaccines are pro-

ective for the patients (35.4 and 37.6%, respectively). Theajority was not immunized against hepatitis B because they

elieve that the vaccine was not useful (42.8%) and unsafe33.3%); whereas, for influenza 89.3% believed that the dis-ase was not dangerous and 28.1% felt they were unlikely tocquire the disease.

From a list of specific sources for information aboutmmunization, 40.8% of the respondents cited scientific jour-als as the main source, followed by vaccination guidelines27.6%), educational courses (22.4%), and dental associ-tions (8.8%). An interesting final result was that 80.8%f dentists expressed interest in more education regardingmmunizations.

. Discussion

The scope of this first comprehensive survey on a repre-entative random sample of dental health-care professionalscross Italy was to provide a lucid description of theirnowledge, attitude, and practicing behavior in respect tommunizations and such understanding is important in ordero assess their effectiveness in the prevention of infectiousiseases. The findings in this study are subjects to certainimitations that warrant consideration. First, even though

follow-up was conducted, replies were received fromewer professionals than desired, though is not uncommonn health-care personnel surveys [12,13]. This may limithe generalizability of the findings and this may mean thathose who did respond tended to support vaccinations andere more likely to be vaccinated and also more knowledge-

ble. Second, immunization status was based on self-reportnd not validated by medical records because our desire forhigh response rate necessitated that surveys be returned

nonymously. This may be biased by participants offering

ocial desirability responses on the most sensitive questions,ncluding immunization attitudes and guidelines compliance.ctual compliance with immunization is probably lower

mong non-respondents while respondent dentists may tend

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25 (2007) 1669–1675 1673

o overestimate the extent to which they comply in practice.naccurate recall of vaccination history can skew the esti-ation of effect of various factors on vaccination status. We

ried to counter and prevent these problems by emphasiz-ng the anonymity and by framing the questions in a way tomprove recall. Indeed, it is well know that when respondentsre provided anonymity and privacy, the use of self-reportedethod is generally considered valid for assessing vaccina-

ion history and for avoiding the problem of unreliable recallf behavior. Third, the analysis is cross-sectional and cannotetermine causal associations.

Dentists’ knowledge of infectious diseases and the nec-ssary control procedures is vital. The results of the generalevel of knowledge of the respondents to our questionnaire,egarding the risk of infectious diseases from their activitynd immunization measures which protect against transmis-ion, suggest that dentists are aware of this aspect. Indeed,nly 44.1 and 32.4% of respondents correctly indicated allnfections that can be acquired or transmitted during theirorking activity, respectively. This information is crucial andot knowing about potential infectious diseases may haveed the dentists to inappropriately triage patients. In addition,t is also evident and of more concern that the dentists intaly lack sufficient knowledge about immunization strategyor dental-care personnel and this explanation may partiallyccount for the observed low rate of compliance with citedmmunization recommendations. The results of the multi-ariate logistic regressions analysis suggest that a numberf demographic and professional characteristics appear to beignificantly associated with the knowledge outcome of inter-st. Specifically, our study indicates that age is directly relatedo the level of knowledge, in that older dentists seem signif-cantly more knowledgeable and, accordingly, junior staffonformably may follow that set example, thus perpetuatinghe cycle. In addition, it is interesting to note that dentistsho have a positive attitude toward vaccinations are signif-

cantly more likely to know that hepatitis B and influenzaaccinations are recommended. This finding implies that pro-essional knowledge equates with positive attitude, namelyhat is important for the dentist receive vaccination againstepatitis B and influenza.

To better assess the level of compliance with the vac-inations among dentists in Italy, our results must beiewed in context with other published research from else-here, although differences in groups of health-care workers

elected do not allow for rigorous comparison. Alarmingly,t should be emphasized that our study revealed dangerouslyow compliance rates. Our rate of influenza immunization,3%, was considerably lower than those observed in sur-eys carried out in the United States with values of 67%mong clinicians in a tertiary-care academic hospital [14],6% among nurses [15], and 51% in those caring for patients

ith spinal cord injuries and disorders [16]. The value inur study was similar to the 37% observed among nursingtaff in Northern Ireland [17], and considerably higher thanhe 22% in Canadian cancer centre staff members [6], and

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674 G. Di Giuseppe et al. /

.6% in health-care workers in two hospitals in the Unitedingdom [18]. We have observed a higher hepatitis B vac-

ination coverage among dentists with less number of yearsf clinical experience and this may be explained as a posi-ive effect of the recommendation by the Italian Minister ofealth that have included hepatitis B vaccine in the volun-

ary program for all health-care workers by 1991. This studyound that a vast majority of respondents stated that theyave received the vaccine against hepatitis B, although only6.2% of those surveyed had completed the entire course ofhree injections and this value was considerably higher thathe 18.1% reported among a small sample of 61 dentists inomania [8] and the 43 and 38.5% found in two studies of,

espectively, 180 dentists in Mexico [9] and 78 in Egypt [7].ur value was lower to the observations of 80.7% in intensive

are unit in Brazil [19] and 65.9% in the already mentionedurses’ study [15]. Finally, our result is consonant with theata of 50.7% in a sample of 146 dentists engaged in clin-cal practice in public hospitals in Nigeria [10]. It shoulde noted that only one-fourth of dentists receive informa-ion by guidelines and a high proportion (80.7%) stated thathey need more information about vaccinations. These results

ay be explained either by an absence of specific guide-ines for dentists in Italy or by an impaired comprehensionf the information already widely distributed. These findingsre of great importance because the strongest predictors ofompleting the hepatitis B vaccination in our multivariateodel were having received information from guidelines,

ourses, and associations and not needing additional infor-ation. Furthermore, the low compliance to immunization

n our sample emphasizes that various strategies should beonsidered to increase the rate of vaccination among dentalealth-care workers such as motivating the personnel to pro-ect themselves and their patients, providing formal trainingnd regular educational programs, and offering campaignshat promote and make vaccines accessible [5,14].

Among respondents there was a clear disparity betweenttitude and stated compliance regarding immunization. It isisturbing that two of every 10 survey dentists reported theyid not receive all recommended immunizations despite theommon perception of the hazard involved and the sample’sverall high positive agreement, with a mean score of 8.5, thataccinations are a useful measure for preventing infectiousiseases. The contradiction is palpable between what den-ists claim to know and how much concern they actually haveersus what they in realty do to protect themselves. In mul-ivariate analysis, positive attitude towards immunization doot influence taking all three doses of the vaccination againstepatitis B or reporting acquired natural immunity. However,t is well known that behavior is influenced by predispos-ng, enabling, and supporting factors, and attitudes pertain toactors giving motivation to behavior. Furthermore, even in

resence of motivation, several barriers may be obstacles toehavior, since enabling factors also play a significant role inetermining behavior. Although an evaluation of the reasonsited for the acceptance or non-acceptance of the vaccinations

25 (2007) 1669–1675

as not the main purpose of the study, our results showed thatepatitis B and influenza vaccines acceptors were more likelyo believe that the vaccine was an effective form of diseaserevention and the hepatitis B was a serious disease. Theost commonly given reasons for refusing immunizations,

n the other hand, were because they believed that they weret low risk of acquiring the diseases, that the hepatitis B vac-ine was unsafe and not useful, and that the influenza wasot dangerous. This result is consistent with those of priorublished studies [5,15,18]. Data from this study, particu-arly the low compliance with influenza vaccination and theeasons stated for non-compliance, suggest that more formaleans must be instituted for those dentists who are fearful

f side effects and new norms must be devised to convincehem that full compliance with immunization is warrantedy virtue of their profession. This is supported by the alreadyentioned low level of knowledge about transmission modes

f infectious diseases and immunizations recommended.In conclusion, our results identify the need that dentists

ould both welcome and benefit from tailored training andducational interventions which would address not only theirnowledge but also would help them to improve immuniza-ion coverage.

cknowledgements

The authors would like to express their appreciation to allhe Colleagues who participated in the study for their time andillingness to share their thoughts regarding vaccinations.

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