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Comparison of attitudes about polio, polio immunization, and barriers to polio eradication between primary health center physicians and private pediatricians in India
International Journal of Infectious Diseases 16 (2012) e417–e423
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International Journal of Infectious Diseases journal homepage: www.elsevier.com/locate/ijid
Comparison of attitudes about polio, polio immunization, and barriers to polio eradication between primary health center physicians and private pediatricians in India Naveen Thacker a, Panna Choudhury a, Lisa M. Gargano b,*, Paul S. Weiss b, Karen Pazol c, Sunil Bahl d, Hamid S. Jafari d, Manisha Arora e, A.P. Dubey a, Vipin M. Vashishtha a, Rohit Agarwal a, Amod Kumar e, Walter A. Orenstein f, Saad B. Omer b, James M. Hughes b a
Indian Academy of Pediatrics (IAP), Mumbai, India Emory University, 1462 Clifton Road NE, Atlanta, GA 30322, USA c Centers for Disease Control and Prevention, Atlanta, Georgia, USA d National Polio Surveillance Project, WHO, New Delhi, India e St. Stephen’s Hospital, Delhi, India f Bill and Melinda Gates Foundation, Seattle, Washington, USA b
A R T I C L E I N F O
S U M M A R Y
Article history: Received 10 November 2011 Accepted 13 February 2012
Objectives: The objectives of this study were to compare attitudes and perceptions of primary health center (PHC) physicians and pediatricians in Uttar Pradesh and Bihar toward polio disease, immunization, and eradication, and to identify barriers to polio eradication. Methods: PHC physicians from blocks with at least one confirmed polio case during January 2006 to June 2009 were selected for an in-person survey. Pediatricians were members of the Indian Academy of Pediatrics and were selected from a national directory of members for telephone or mail survey. Results: A higher percentage of PHC physicians than pediatricians reported that an unvaccinated child was susceptible to polio (82.1% vs. 63.0%, p < 0.0001) and that polio disease was severe in a child aged 1– 5 years (77.7% vs. 62.2%, p < 0.0001). PHC physicians and pediatricians expressed confidence in the protectiveness and safety of oral polio vaccine and cited parents’ lack of awareness of the importance of polio eradication as an important barrier to eradication. Strengthening routine immunization efforts was reported as the leading intervention required to eradicate polio. Conclusions: PHC physicians and pediatricians support and have confidence in the success of polio eradication efforts. These findings will be useful for policy-makers involved in the planning of eradication strategies. Providers and parents need to maintain confidence in polio vaccination if polio is to be eradicated. ß 2012 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Corresponding Editor: William Cameron, Ottawa, Canada Keywords: Polio Indian Academy of Pediatrics Primary health centers India Eradication
1. Introduction The Global Poliomyelitis Eradication Initiative has reported substantial progress since 1988, when the World Health Assembly resolved to eradicate poliomyelitis by 2000.1 The success of the Global Polio Eradication Initiative has been remarkable, but four countries – Afghanistan, Pakistan, India, and Nigeria – remain endemic for wild polio virus transmission. Among the four endemic countries, India is the most populous.2 There has been only one reported case of wild poliovirus in India since January 2011 – from West Bengal, a non-endemic state. The key endemic
* Corresponding author. Tel.: +1 404 712 2225; fax: +1 404 712 2557. E-mail address: [email protected] (L.M. Gargano).
states of Uttar Pradesh (UP) and Bihar have not reported a single wild poliovirus case since April 2010 and September 2010, respectively.3a Until recently, transmission of wild poliovirus has remained endemic in areas of western UP and central Bihar. Nearly 32% of the total population of India resides in UP and Bihar, but until very recently about 98% of polio cases were reported from these two states.4 These states also have some of the lowest routine immunization rates in the country, as evaluated by coverage surveys. Despite significant improvements in routine immunization in Bihar during recent years, only 61.6% of children in the 12–
a In January 2012 India was removed from the list of countries with endemic wild polio virus
1201-9712/$36.00 – see front matter ß 2012 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijid.2012.02.002
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23 months age group had received three doses of oral polio vaccine (OPV) through routine immunization in 2009–2010, as per a coverage assessment. Routine immunization coverage has been even lower in UP, with only 53.9% of children in the 12–23 months age group having received three doses of polio vaccine through routine immunization in 2009–2010.5 Research from the USA has shown the critical role of immunization providers in contributing to high immunization rates.6 It is essential to identify and overcome the barriers that physicians may encounter in order to reach children for vaccination through immunization campaigns and routine immunization services. In India, public sector primary health center (PHC) physicians are respected leaders in a system that delivers a large majority of the vaccines to children.7–9 PHC physicians work in the public sector in both urban and rural areas, providing health care primarily to patients from the lower socio-economic strata of society. Pediatricians work mostly in the private sector and provide care mostly to the more affluent sections of society, primarily in urban areas. PHC physicians and private sector pediatricians provide leadership in their communities and are among key opinion leaders for health care at the national and state level. Their perceptions covering various aspects of polio immunization and their practices in this regard are of immense importance for the success of polio eradication in India. This study assessed the attitudes and practices of PHC physicians and pediatricians in UP and Bihar regarding polio disease, polio immunization, and barriers to polio eradication. Understanding the attitudes of PHC physicians and pediatricians in these two states is key during this final phase of polio eradication in India. The objectives of this study were to (1) compare attitudes and perceptions of PHC physicians in UP and Bihar with those of pediatricians in the two states toward polio disease, polio immunization, and polio eradication, and (2) identify important strategies and barriers to polio eradication. 2. Methods 2.1. Participants Participants consisted of PHC physicians and pediatricians who are members of the Indian Academy of Pediatrics (IAP) in UP and Bihar.
sub-section of a district that has one block primary health center/ community health center covering a population of 100 000 or more. First, geographically contiguous districts were selected in UP and Bihar based on the detection of at least one virologically confirmed case of polio between January 2006 and June 2009. Twenty-six districts in UP and 12 districts in Bihar were selected. A total of 275 blocks in UP and 132 in Bihar were then randomly selected. For the sampling frame, the PHCs within the selected blocks were enumerated to provide a list from which individuals could be randomly sampled. In UP, 614 PHCs were selected, and in Bihar, 159 PHCs were selected; the PHC physician in clinic on the day of the survey was asked to participate. Verbal consent was obtained to avoid the need to retain individual identifiers. With regard to the pediatricians, an independent random sample of members with a telephone number available was generated for the telephone survey, and then a second sample for whom no telephone number was available plus those with a telephone number available who were not selected for the telephone survey was generated for the mail survey. IAP members without telephone availability could not be randomized to the telephone survey. For both groups, members selected for participation first received a telephone call to solicit their participation using the contact information provided by the IAP office. During this call, persons randomized to the mail survey were asked for their mailing address. Persons in the telephone group were asked if they presently had time to complete the survey, or if there was a convenient time for them to be called back. Persons in the mail group who accepted the invitation to participate were called up to two more times to encourage them to submit their responses. If IAP members in either group were not reachable by telephone, a mail survey was sent with a letter of invitation to the address on file with the IAP office. Persons in both groups received a letter signed by the IAP president thanking them for their participation. Verbal consent was obtained to avoid the need to retain individual identifiers. The Institutional Review Board of Emory University and the Institutional Ethics Committee of Maulana Azad Medical College both determined that this study did not meet the definition of ‘Human Subjects Research’ and was considered ‘Quality Improvement’, and therefore did not need review. 2.4. Instrument
2.2. Formative research PHC physicians were recruited for focus group discussions to provide input on the contents of the survey instrument and to assess the possible utility of data likely to be generated from the survey. The survey instrument developed following the focus group discussion was then pilot tested on PHC physicians in Delhi. Verbal consent was obtained to avoid the need to retain individual identifiers. Following the pilot survey, the number of Likert scale answer options was reduced from five to three. With regard to the pediatricians, focus group discussions were designed to provide input on the contents of the survey instrument and assess the possible utility of data likely to be obtained from the survey. The survey instrument developed following the focus group discussions was then pilot tested on selected pediatricians by telephone and in person. Verbal consent was obtained at the beginning of the focus group and individual identifiers were not retained. Following the pilot surveys the Likert scale answer options were reduced from five to three. 2.3. Surveys PHC physicians in UP and Bihar were surveyed in-person. The primary sampling unit was a block. In most of India a block is a
The survey instrument was designed to assess attitudes and practices associated with routine immunization, vaccine cold chain, polio disease, polio immunization, polio eradication, and barriers to achieving polio eradication. The instrument consisted of 27 questions and took approximately 30 min to complete. Survey items were guided by the Health Belief Model (HBM).10 2.5. Measures The survey assessed the following attitudes and beliefs toward polio and polio immunization on a three-point Likert scale. The questionnaire addressed perceived susceptibility (‘‘How likely do you think a child in India under 5 years of age who has received no vaccine when due is to get the following diseases within the next year?’’; ‘likely’ to ‘not likely’), perceived severity (‘‘If a child under 1 year of age gets the following diseases, how likely is that child to be seriously ill?’’; ‘likely’ to ‘not likely’), perceived vaccine protectiveness (‘‘How protective do you think each of these vaccines is against disease?’’; ‘protective’, ‘somewhat protective’, ‘not very protective’), perceived vaccine safety (‘‘How safe do you think these vaccines are?’’; ‘safe’ to ‘unsafe’), and perceived barriers (‘‘How important are the following barriers to polio eradication?’’; ‘important’ to ‘not important’). Questions assessing attitudes about
<0.0001 148 (62.2) 0.60 80 (64) 68 (60.2) PHC, primary health center; UP, Uttar Pradesh. a Compares states. b Compares PHC physicians and pediatricians with both states combined, adjusted p-value = 0.007.
561 (77.7) 453 (78.0) 108 (76.6)
0.72
150 (63.0) 175 (73.5) 0.81 0.28 80 (64) 96 (76.8) 70 (61.9) 79 (69.9) 593 (82.1) 578 (80.1) 0.98 0.63
p-Valuea UP (581 responses) Bihar (141 responses)
The majority of PHC physicians and pediatricians reported that an unvaccinated child is susceptible to polio (82.1% and 63.0%, respectively) and that the disease is severe in both infants aged under 1 year (80.1% and 73.5%) and in children aged 1–5 years (77.7% and 62.2%) (Table 1). A higher percentage of PHC physicians compared to pediatricians reported that a child under the age of 5 years was likely to become seriously ill if they got polio disease (p < 0.0001) (Table 1). A significantly higher percentage of PHC physicians compared to pediatricians reported that the likelihood of an unvaccinated child getting polio disease was high (p < 0.0001) (Table 1). There were no significant differences in perceived susceptibility among unvaccinated children or severity of polio disease between the respective PHC physicians and pediatricians in each state. Both PHC physicians and pediatricians reported confidence in the protectiveness (PHC physicians 99.0%, pediatricians 76.5%) and safety (PHC physicians 96.8%, pediatricians 91.2%) of the OPV (Table 2). However a higher percentage of pediatricians believed in the protectiveness (84.5%) and safety (88.2%) of inactivated polio vaccine (IPV) than PHC physicians (protectiveness: 83.7%, p = 0.77; safety: 71.3% p < 0.0001). A comparison of the responses of PHC physicians between UP and Bihar indicated that a higher proportion of the PHC physicians in UP felt that IPV was protective (85.9%) compared to PHC physicians in Bihar (protective, 74.5% p = 0.001). There were no significant differences in the responses among pediatricians from UP and Bihar regarding perceptions of polio vaccine protectiveness and safety.
Table 1 PHC physician and pediatrician perceptions of susceptibility to and severity of polio disease
3.2. Comparison of PHC physician and pediatrician perceptions about polio disease and polio vaccine safety
PHC physicians, n (%)
Total (722 responses)
A total of 398 out of 785 surveys (50.7%) were completed in the national survey of pediatricians. Of these surveys, 275 were from UP, of which 125 were completed (45.5%), and 230 were from Bihar, of which 113 were completed (49.1%). In UP, 581 of 614 PHC physicians selected completed the survey (94.6%). In Bihar, 141 of 159 PHC physicians selected completed the survey (88.7%). Overall 93.4% of PHC physician surveys were completed (722 out of 773).
477 (82.1) 463 (79.7)
3.1. Response rate
116 (82.3) 115 (81.6)
3. Results
Likelihood of polio in unvaccinated child Likelihood of becoming seriously ill with polio aged <1 year Likelihood of becoming seriously ill with polio aged between 1 and <5 years
Bihar (113 responses)
Pediatricians, n (%)
Data management and analysis was conducted using SAS version 9.2. Pen-and-paper and telephone survey responses from IAP members were combined. Descriptive analyses were performed to assess the distributions of variables assessing poliorelated attitudes and behaviors among PHC physicians and pediatricians. Chi-square analyses were conducted to assess differences in responses between the two sets of health care professionals in UP and Bihar. For comparisons between PHC and IAP physicians on attitudes and barriers, questions were adjusted for multiple tests using a Bonferroni’s adjustment, which reduced the p-value for significance to 0.007.
UP (125 responses)
2.6. Data analysis
p-Valuea
Total (238 responses)
p-Valueb
polio eradication included ‘‘How likely do you think it is that we will eradicate polio?’’ (‘likely’ to ‘not likely’) and ‘‘How important are the following barriers to polio eradication?’’ (‘important’ to ‘not important’). Questions assessing immunization practices included ‘‘How much time is devoted to polio eradication and other immunization services?’’ by the PHC physicians.
e419 <0.0001 0.26
N. Thacker et al. / International Journal of Infectious Diseases 16 (2012) e417–e423
N. Thacker et al. / International Journal of Infectious Diseases 16 (2012) e417–e423
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Table 2 PHC physician and pediatrician perceptions of polio vaccine protectiveness and safety PHC physicians, n (%)
Protectiveness of oral polio vaccine Protectiveness of inactivated polio vaccine Safety of oral polio vaccine Safety of inactivated polio vaccine
Pediatricians, n (%) a
Bihar (141 responses)
UP (581 responses)
p-Value
138 (97.9)
577 (99.3)
0.28
715 (99.0)
86 (76.1)
105 (74.5)
499 (85.9)
0.001
604 (83.7)
94 (83.2)
136 (96.5)
563 (96.9)
0.76
699 (96.8)
107 (94.7)
91 (64.5)
424 (73.0)
0.05
515 (71.3)
97 (85.8)
Total (722 responses)
Bihar (113 responses)
p-Valuea
Total (238 responses)
p-Valueb
96 (76.8)
0.81
182 (76.5)
<0.0001
107 (85.6)
0.51
201 (84.5)
0.77
110 (88)
0.10
217 (91.2)
0.0007
113 (90.4)
0.20
210 (88.2)
<0.0001
UP (125 responses)
PHC, primary health center; UP, Uttar Pradesh. a Compares states. b Compares PHC physicians and pediatricians with both states combined, adjusted p-value = 0.007.
Table 3 PHC physician and pediatrician perceptions of the importance of eradicating polio and the likelihood of achieving eradication PHC physicians, n (%)
Important to eradicate polio Likelihood of polio being eradicated
Pediatricians, n (%) Total (718 responses)
Bihar (113 responses)
UP (123 responses)
p-Valuea
Total (236 responses)
p-Valueb
0.57
715 (99.6)
113 (100)
123 (100)
0.15
236 (100)
0.65
0.03
671 (93.5)
107 (94.7)
110 (89.4)
0.08
217 (91.9)
0.43
Bihar (137 responses)
UP (581 responses)
p-Value
136 (99.3)
579 (99.7)
122 (89.1)
549 (94.5)
a
PHC, primary health center; UP, Uttar Pradesh. a Compares states. b Compares PHC physicians and pediatricians with both states combined, adjusted p-value = 0.007.
3.3. Comparison of attitudes about polio eradication, barriers to eradication, and strategies for eradication among PHC physicians and pediatricians Nearly all PHC physicians and pediatricians in UP and Bihar believed that it is important to eradicate polio (99.6% and 100%, respectively). In addition, 93.5% of PHC physicians and 91.9% of pediatricians reported that it is very likely that polio will be eradicated (Table 3). Although not significant, more PHC physicians in UP (94.5%) than in Bihar (89.1%) believed that polio will be eradicated (p = 0.03) (Table 3). Parents’ lack of awareness of the importance of polio eradication efforts was the most common reported barrier by both PHC
physicians and pediatricians. More PHC physicians than pediatricians reported a lack of awareness of the importance of polio eradication among parents (94.3% vs. 85.5%, p < 0.0001), lack of confidence in polio vaccine amongst parents (82.0% vs. 69.2%, p < 0.0001), a fear of side effects of polio vaccine amongst parents (75.5% vs. 63.2%, p = 0.0003), and cultural beliefs of parents (64.6% vs. 52.6%, p = 0.001), as important barriers to polio eradication (Table 4). The most common reported barrier by PHC physicians in both UP and Bihar was the lack of awareness of the importance of the polio eradication effort among parents (94.7% and 92.7%, respectively). Significantly more PHC physicians in UP than in Bihar reported parents’ lack of confidence in polio vaccine (84.3% vs. 72.3%, p = 0.001), parents’ religious beliefs regarding polio vaccine (81.2%
Table 4 PHC physician and pediatrician perceptions of the importance of barriers to polio eradication PHC physicians, n (%)
Pediatricians, n (%)
UP p-Valuea Total Bihar UP p-Valuea Total p-Valueb Bihar (718 responses) (113 responses) (121 responses) (234 responses) (137 responses) (581 responses) Parent’s lack of awareness 127 (92.7) of the importance of the polio eradication Parent’s lack of confidence 99 (72.3) in polio vaccine Parents’ religious beliefs 78 (56.9) regarding polio vaccine 85 (62.0) Parent’s fear of side effects of polio vaccine Lack of time or priority 70 (51.1) for parents 70 (51.1) Superstition Parents cultural 66 (48.2) beliefs PHC, primary health center; UP, Uttar Pradesh. a Compares states. b Compares PHC physicians and pediatricians
550 (94.7)
0.38
677 (94.3)
100 (88.5)
100 (82.6)
0.21
200 (85.5)
<0.0001
490 (84.3)
0.001
589 (82.0)
72 (63.7)
90 (74.4)
0.08
162 (69.2)
<0.0001
472 (81.2)
<0.0001
550 (76.6)
73 (64.6)
86 (71.1)
0.29
159 (67.9)
0.008
457 (78.7)
<0.0001
542 (75.5)
72 (63.7)
76 (62.8)
0.89
148 (63.2)
0.0003
416 (71.6)
<0.0001
486 (67.7)
65 (57.5)
71 (58.7)
0.86
136 (58.1)
0.008
407 (70.1) 398 (68.5)
<0.0001 <0.0001
477 (66.4) 464 (64.6)
60 (53.1) 58 (51.3)
73 (60.3) 65 (53.7)
0.27 0.71
133 (56.8) 123 (52.6)
0.008 0.001
with both states combined, adjusted p-value = 0.007.
N/A
PHC, primary health center; UP, Uttar Pradesh; IPV, inactivated polio vaccine; OPV, oral polio vaccine; DTaP, diphtheria–tetanus–acellular pertussis; HBV, hepatitis B virus; N/A, not asked. a Compares states. b Compares PHC physicians and pediatricians with both states combined, adjusted p-value = 0.007.
N/A N/A N/A N/A 337 (46.9) 295 (50.8) 42 (30.4)
<0.0001
N/A N/A N/A N/A N/A 356 (49.5) 0.01 301 (51.8) 55 (39.9)
0.24 <0.0001 <0.0001 <0.0001 N/A 228 (96.6) 178 (75.4) 91 (38.6) 139 (58.9) N/A 0.40 0.15 0.80 0.14 N/A 120 (97.6) 88 (71.5) 54 (43.9) 78 (63.4) N/A 108 (95.6) 90 (79.6) 37 (32.7) 61 (54.0) N/A (94.7) (47.3) (67.3) (76.8) (72.0) 681 340 484 552 518 0.06 0.17 0.04 <0.0001 0.18 (95.5) (48.5) (65.6) (83.1) (73.1)
p-Value UP (581 responses)
555 282 381 483 425 (91.3) (42.0) (74.6) (50) (67.4) 126 58 103 69 93
Total (236 responses) p-Valuea UP (123 responses) Total (719 responses)
Bihar (113 responses)
Pediatricians, n (%)
a
PHC physicians, n (%)
e421
Strengthening routine immunization Use of mass campaigns with IPV in UP and Bihar Use of mass campaigns with monovalent polio vaccine in UP and Bihar Use of mass campaigns with bivalent polio vaccine in UP and Bihar Trivalent OPV for mass campaigns in UP and Bihar (contains all three polio types, 1, 2, and 3) Use of IPV during routine immunizations, in addition to OPV (such as a schedule of IPV followed by OPV at a separate office visit) If it is used, how important is it that IPV be given as a single vaccine as opposed to a combination vaccine (for example DTaP–IPV or DTaP–IPV–HBV combination vaccine)
The study revealed that PHC physicians in Bihar are devoting more time to immunization activities, including polio, than their counterparts in UP. The percentage of PHC physicians devoting 75– 100% of their time to immunization activities in Bihar was 32.3% vs. only 13.2% in UP. Of the time they are spending on immunization activities, 22.2% of PHC physicians in Bihar are spending 75–100% on planning, supporting, coordinating, and supervising routine immunization services, compared to 5.7% in UP. In Bihar, 27.6% of PHC physicians reported spending 75–100% on planning, supporting, coordinating, and supervising polio-related activities, compared to 5.7% in UP. In Bihar, 19.3% of PHC physicians reported spending 75–100% of their time on data analysis and reporting for routine immunization, compared to 4.3% in UP. Similarly, 19.3% of PHC physicians in Bihar reported spending 75–100% of their time on data analysis and reporting for polio compared to 4.5% of PHC physicians in UP. In their respective states, PHC physicians are devoting almost equal time to both routine immunization and polio vaccination; however, the PHC physicians in Bihar are devoting more time to both routine immunization and polio vaccination than their counterparts in UP.
Bihar (138 responses)
3.4. Practices of PHC physicians regarding polio activities compared to other activities
Table 5 PHC physician and pediatrician perceptions of strategies important for the elimination of polio in endemic areas
vs. 56.9%, p < 0.0001), parents’ fear of side effects (78.7% vs. 62.0%, p < 0.0001), lack of time or priority for parents (71.6% vs. 51.1%, p < 0.0001), superstition (70.1% vs. 51.1%, p < 0.0001), and parents’ cultural beliefs (68.5% vs. 48.2%, p < 0.0001) as barriers to eradication (Table 4). In contrast, there was no difference in reported barriers by pediatricians from UP and Bihar. When asked to list the two most important barriers to polio eradication, ‘‘Parents’ lack of awareness of the importance of polio eradication’’ was the most significant barrier among both groups: PHC physicians (57.0%) and pediatricians (54.0%). This barrier was listed as most important among respondents from both Bihar (PHC physicians 67.8% and pediatricians 54.5%) and UP (PHC physicians 51.8% and pediatricians 55.3%). However, PHC physicians and pediatricians differed with regard to the perception of the second most important barrier: ‘‘Parents’ fear of side effects of polio vaccine’’ was the perceived reason among PHC physicians (23.2%), whereas pediatricians believed ‘‘Parents’ religious beliefs regarding polio vaccine’’ was the second most important reason (21.4%). A high percentage of PHC physicians (94.7%) and pediatricians (96.6%) in the two states reported that strengthening routine immunization is an important strategy for eliminating polio in endemic areas. The PHC physicians were more supportive than pediatricians of mass campaigns with monovalent oral polio vaccine (mOPV) in UP and Bihar (67.3% and 38.6%, respectively, p < 0.0001) and mass campaigns with bivalent oral polio vaccine (bOPV) in UP and Bihar (76.8% and 58.9%, respectively, p < 0.0001) (Table 5). On the other hand, pediatricians were more supportive than PHC physicians of mass campaigns with IPV in UP and Bihar (75.4% and 47.3%, respectively, p < 0.0001). The PHC physicians in Bihar were more supportive of mass campaigns using mOPV in UP and Bihar than PHC physicians in UP (74.6% and 65.6%, respectively, p = 0.04). The PHC physicians in UP were significantly more supportive of mass campaigns using bOPV in UP and Bihar than PHC physicians in Bihar (83.1% and 50%, p < 0.0001). PHC physicians in UP were also more supportive than PHC physicians in Bihar of strategies that included the use of IPV during routine immunization, in addition to OPV (51.8% and 39.9%, respectively, p = 0.01). Also, a higher percentage of PHC physicians in UP than in Bihar felt it would be important that IPV be given as a single vaccine as opposed to a combination vaccine (50.8% and 30.4%, respectively, p < 0.0001) (Table 5).
p-Valueb
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In response to the question ‘‘What would they devote their time to if they did not have to do SIAs [supplementary immunization activities] for polio?’’, a majority of PHC physicians in UP mentioned that they would devote their time to clinical work, followed by routine immunization, while in Bihar PHC physicians reported that they would prefer to devote more time to routine immunization, followed by clinical work. 4. Discussion Our data show that polio eradication efforts continue to have strong support from PHC physicians and pediatricians in high-risk states. Continued support of the medical profession is critically important so that there is no complacency among key opinion leaders in these efforts. Importantly, 92% of pediatricians and 94% of PHC physicians believe that polio will be eradicated. This belief is relatively stronger among PHC physicians in Bihar and pediatricians in UP. As physicians have influence on policy-makers and the public in their communities, it may be important to further increase their confidence in the eradication of polio. The results of this survey show that the majority of these physicians from UP and Bihar perceive that an unvaccinated child is susceptible to polio and that infants and children are likely to develop severe disease if they get polio. However, PHC physicians were generally more concerned than pediatricians about the likelihood of polio and its severity in young unvaccinated children. This observation was similar in both UP and Bihar. Physician perceptions of the protectiveness and safety of the polio vaccine are important in motivating physicians to encourage parents to have their child vaccinated, in order to achieve high immunization coverage, and are very relevant for polio eradication efforts. In India OPV has been used as the primary eradication strategy, and most countries in the world have achieved polio eradication using only OPV. The IPV has recently been licensed in the country and is being used in the private sector on a limited scale.11 Whether IPV should be used in the public sector for intensifying polio eradication efforts has been debated.12,13 This study shows that physicians in general consider both OPV and IPV to be protective and safe. Pediatricians were convinced of the protectiveness of OPV, but in comparison with PHC physicians, they had slightly more faith in the efficacy of IPV. This could be due to the fact that IPV is being used primarily by pediatricians in the private sector who are therefore more familiar with it. As the confidence of physicians in polio vaccines is important in building and maintaining the trust of parents, these survey results could positively influence polio eradication efforts. Physician perceptions of barriers to polio eradication are very important, as they are in close contact with the community. Though several barriers were identified, parents’ perceived lack of awareness of the importance of polio eradication and parents’ perceived lack of confidence in polio vaccine stand out as the most important. Interestingly, PHC physicians believed these barriers to be more serious than pediatricians. This survey also tried to determine the relative importance of the two most important barriers identified by PHC physicians and pediatricians. While parents’ perceived lack of awareness about the importance of polio continues to be the main factor in both states, there were some interesting differences identified for the second factor. For pediatricians in UP, this was lack of confidence in polio vaccine, while in Bihar it was parents’ religious beliefs regarding polio vaccine. For PHC physicians in UP, superstition was cited as the second most important barrier, while in Bihar it was fear of side effects of polio vaccine. Intensive polio immunization campaigns with trivalent OPV have proved successful for the elimination of polio virus in Indian states other than UP and Bihar.14 The resurgence of polio cases in
2002 and again in 2006–07 in these two states led to serious setbacks in national polio eradication efforts.15,16 This led to the introduction of new technical strategies and innovations in the program, including the use of monovalent vaccines and recently the use of bivalent vaccine.17,18 There has been an ongoing debate about the use of IPV in the program in recent years.19 PHC physicians and pediatricians in UP and Bihar strongly supported routine immunization as an important strategy for eradicating polio. Mass campaigns were also considered an important strategy for polio eradication; however, PHC physicians and pediatricians differed on the type of polio vaccines that should be used in mass campaigns. PHC physicians have more faith in mOPV and bOPV, while pediatricians feel that IPV is more appropriate. The lack of support for bOPV among PHC physicians from Bihar (50%) is a matter of concern, as bOPV has recently been the most important tool responsible for the success of the Global Poliomyelitis Eradication Initiative in these two endemic states.3 This may have been due to the timing of the study; bOPV was introduced in India in January 2010 while this survey was conducted between June 2009 and June 2010, and the impact of bOPV was not evident while this study was being conducted. Regarding the use of IPV during routine immunization in addition to OPV, PHC physicians from UP were more supportive than their counterparts in Bihar. PHC physicians in UP would prefer to use IPV as a single vaccine rather than a combination vaccine if it were used in the program.17 These findings should be of great interest to policy-makers and planners when consideration is given to modifying the type of vaccine to be used during the end stages of eradication or in the post-eradication phase. It is very important to instill confidence in the polio eradication program in both providers and parents if polio transmission is to be interrupted in the near future. 4.1. Limitations The national survey that provided the pediatrician data was cross-sectional in nature, and 49% of pediatricians selected did not complete the survey despite multiple follow-up attempts; this may have resulted in some response bias. The PHC physician surveys were done in-person, which may have resulted in a social desirability bias in their responses. Although confidentiality and anonymity of the respondents were maintained, there is a possibility that respondents may have overestimated their compliance with and support of recommendations from the IAP or the government.
5. Conclusions The findings of the current study provide reassurance that there is a very high level of support for polio eradication activities among both PHC physicians and pediatricians, the two key health care providers for children in India. Polio-related immunization is still accorded very high priority among health care professionals in India. They are confident that polio will be eradicated from India very soon. They have a high level of confidence in the safety and protective efficacy of both OPVs and IPV. Both PHC physicians and pediatricians are unanimous in advocating the strengthening of routine immunization efforts as one of the important strategies for the elimination of polio in endemic areas, in addition to mass campaigns. The study also provides a glimpse of a few important barriers that need to be addressed urgently in order to achieve high immunization rates in the two highly endemic states. These findings should be of great interest to policy-makers and planners in considering the need for modifications to polio eradication strategies to achieve rapid interruption of wild virus transmission and to sustain eradication once it is achieved.
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Acknowledgements We would like to thank our survey participants, Dianne Miller and Ashley Freeman at Emory University for their administrative support, the Executive Board members of IAP, and the staff of St. Stephens Hospital, especially Vipin Gupta. We also thank Surveillance Medical Officers at the National Polio Surveillance Project (NPSP) and the governments of Uttar Pradesh and Bihar for their support of the project. This work was supported by grant #50230 from the Bill and Melinda Gates Foundation. Conflict of interest: The authors have no financial or personal relationships to disclose. References 1. World Health Organization. Polio eradication. Geneva: WHO; 2012. Available at: http://www.who.int/trade/distance_learning/gpgh/gpgh2/en/index3.html (accessed February 2012). 2. World Health Organization. Global Polio Eradication Initiative: annual report 2007–2008. Geneva: WHO; 2009. 3. Centers for Disease Control and Prevention. Progress toward interruption of wild poliovirus transmission—worldwide, January 2010–March 2011. MMWR Morb Mortal Wkly Rep 2011;60:582–6. 4. Paul Y. Why polio has not been eradicated in India despite many remedial interventions? Vaccine 2009;27:3700–3. 5. United Nations Children’s Fund (UNICEF). Coverage evaluation survey report 2009. New Delhi: UNICEF; 2009. Available at: http://www.unicef.org/india/1__CES_2009_All_India_Report.pdf (accessed September 12, 2011).
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6. Salmon DA, Pan WK, Omer SB, Navar AM, Orenstein W, Marcuse EK, et al. Vaccine knowledge and practices of primary care providers of exempt vs. vaccinated children. Hum Vaccin 2008;4:286–91. 7. Agampodi SB, Amarasinghe DA. Private sector contribution to childhood immunization: Sri Lankan experience. Indian J Med Sci 2007;61:192–200. 8. Chhabra P, Nair P, Gupta A, Sandhir M, Kannan AT. Immunization in urbanized villages of Delhi. Indian J Pediatr 2007;74:131–4. 9. Jain SK, Chawla U, Gupta N, Gupta RS, Venkatesh S, Lal S. Child survival and safe motherhood program in Rajasthan. Indian J Pediatr 2006;73:43–7. 10. Rosenstock I. Historical origins of the Health Belief Model. Health Education Monographs 1974;2:328–35. 11. Krishnan R, Jadhav M, John TJ. Efficacy of inactivated poliovirus vaccine in India. Bull World Health Organ 1983;61:689–92. 12. John TJ, Vashishtha VM. Eradication of vaccine polioviruses: why, when & how? Indian J Med Res 2009;130:491–4. 13. Vashishtha VM, John TJ, Agarwal RK, Kalra A. Universal immunization program and polio eradication in India. Indian Pediatr 2008;45:807–13. 14. World Health Organization. Progress towards interrupting wild poliovirus transmission worldwide, 2009. Wkly Epidemiol Rec 2010;85:178–84. 15. Centers for Disease Control and Prevention. Progress toward poliomyelitis eradication—India, 2002. MMWR Morb Mortal Wkly Rep 2003;52:172–5. 16. Centers for Disease Control and Prevention. Progress toward poliomyelitis eradication—India, January 2006–September 2007. MMWR Morb Mortal Wkly Rep 2007;56:1187–91. 17. Sutter RW, John TJ, Jain H, Agarkhedkar S, Ramanan PV, Verma H, et al. Immunogenicity of bivalent types 1 and 3 oral poliovirus vaccine: a randomised, double-blind, controlled trial. Lancet 2010;376:1682–8. 18. World Health Organization. Conclusions and recommendations of the Advisory Committee on Poliomyelitis Eradication, November 2009. Special consultation with polio-infected countries and global management team partners, Geneva, 18–19 November 2009. Wkly Epidemiol Rec 2010;85:1–11. 19. Paul Y. Oral polio vaccines and their role in polio eradication in India. Expert Rev Vaccines 2009;8:35–41.
Contents lists available at SciVerse ScienceDirect
International Journal of Infectious Diseases journal homepage: www.elsevier.com/locate/ijid
Comparison of attitudes about polio, polio immunization, and barriers to polio eradication between primary health center physicians and private pediatricians in India Naveen Thacker a, Panna Choudhury a, Lisa M. Gargano b,*, Paul S. Weiss b, Karen Pazol c, Sunil Bahl d, Hamid S. Jafari d, Manisha Arora e, A.P. Dubey a, Vipin M. Vashishtha a, Rohit Agarwal a, Amod Kumar e, Walter A. Orenstein f, Saad B. Omer b, James M. Hughes b a
Indian Academy of Pediatrics (IAP), Mumbai, India Emory University, 1462 Clifton Road NE, Atlanta, GA 30322, USA c Centers for Disease Control and Prevention, Atlanta, Georgia, USA d National Polio Surveillance Project, WHO, New Delhi, India e St. Stephen’s Hospital, Delhi, India f Bill and Melinda Gates Foundation, Seattle, Washington, USA b
A R T I C L E I N F O
S U M M A R Y
Article history: Received 10 November 2011 Accepted 13 February 2012
Objectives: The objectives of this study were to compare attitudes and perceptions of primary health center (PHC) physicians and pediatricians in Uttar Pradesh and Bihar toward polio disease, immunization, and eradication, and to identify barriers to polio eradication. Methods: PHC physicians from blocks with at least one confirmed polio case during January 2006 to June 2009 were selected for an in-person survey. Pediatricians were members of the Indian Academy of Pediatrics and were selected from a national directory of members for telephone or mail survey. Results: A higher percentage of PHC physicians than pediatricians reported that an unvaccinated child was susceptible to polio (82.1% vs. 63.0%, p < 0.0001) and that polio disease was severe in a child aged 1– 5 years (77.7% vs. 62.2%, p < 0.0001). PHC physicians and pediatricians expressed confidence in the protectiveness and safety of oral polio vaccine and cited parents’ lack of awareness of the importance of polio eradication as an important barrier to eradication. Strengthening routine immunization efforts was reported as the leading intervention required to eradicate polio. Conclusions: PHC physicians and pediatricians support and have confidence in the success of polio eradication efforts. These findings will be useful for policy-makers involved in the planning of eradication strategies. Providers and parents need to maintain confidence in polio vaccination if polio is to be eradicated. ß 2012 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Corresponding Editor: William Cameron, Ottawa, Canada Keywords: Polio Indian Academy of Pediatrics Primary health centers India Eradication
1. Introduction The Global Poliomyelitis Eradication Initiative has reported substantial progress since 1988, when the World Health Assembly resolved to eradicate poliomyelitis by 2000.1 The success of the Global Polio Eradication Initiative has been remarkable, but four countries – Afghanistan, Pakistan, India, and Nigeria – remain endemic for wild polio virus transmission. Among the four endemic countries, India is the most populous.2 There has been only one reported case of wild poliovirus in India since January 2011 – from West Bengal, a non-endemic state. The key endemic
* Corresponding author. Tel.: +1 404 712 2225; fax: +1 404 712 2557. E-mail address: [email protected] (L.M. Gargano).
states of Uttar Pradesh (UP) and Bihar have not reported a single wild poliovirus case since April 2010 and September 2010, respectively.3a Until recently, transmission of wild poliovirus has remained endemic in areas of western UP and central Bihar. Nearly 32% of the total population of India resides in UP and Bihar, but until very recently about 98% of polio cases were reported from these two states.4 These states also have some of the lowest routine immunization rates in the country, as evaluated by coverage surveys. Despite significant improvements in routine immunization in Bihar during recent years, only 61.6% of children in the 12–
a In January 2012 India was removed from the list of countries with endemic wild polio virus
1201-9712/$36.00 – see front matter ß 2012 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijid.2012.02.002
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23 months age group had received three doses of oral polio vaccine (OPV) through routine immunization in 2009–2010, as per a coverage assessment. Routine immunization coverage has been even lower in UP, with only 53.9% of children in the 12–23 months age group having received three doses of polio vaccine through routine immunization in 2009–2010.5 Research from the USA has shown the critical role of immunization providers in contributing to high immunization rates.6 It is essential to identify and overcome the barriers that physicians may encounter in order to reach children for vaccination through immunization campaigns and routine immunization services. In India, public sector primary health center (PHC) physicians are respected leaders in a system that delivers a large majority of the vaccines to children.7–9 PHC physicians work in the public sector in both urban and rural areas, providing health care primarily to patients from the lower socio-economic strata of society. Pediatricians work mostly in the private sector and provide care mostly to the more affluent sections of society, primarily in urban areas. PHC physicians and private sector pediatricians provide leadership in their communities and are among key opinion leaders for health care at the national and state level. Their perceptions covering various aspects of polio immunization and their practices in this regard are of immense importance for the success of polio eradication in India. This study assessed the attitudes and practices of PHC physicians and pediatricians in UP and Bihar regarding polio disease, polio immunization, and barriers to polio eradication. Understanding the attitudes of PHC physicians and pediatricians in these two states is key during this final phase of polio eradication in India. The objectives of this study were to (1) compare attitudes and perceptions of PHC physicians in UP and Bihar with those of pediatricians in the two states toward polio disease, polio immunization, and polio eradication, and (2) identify important strategies and barriers to polio eradication. 2. Methods 2.1. Participants Participants consisted of PHC physicians and pediatricians who are members of the Indian Academy of Pediatrics (IAP) in UP and Bihar.
sub-section of a district that has one block primary health center/ community health center covering a population of 100 000 or more. First, geographically contiguous districts were selected in UP and Bihar based on the detection of at least one virologically confirmed case of polio between January 2006 and June 2009. Twenty-six districts in UP and 12 districts in Bihar were selected. A total of 275 blocks in UP and 132 in Bihar were then randomly selected. For the sampling frame, the PHCs within the selected blocks were enumerated to provide a list from which individuals could be randomly sampled. In UP, 614 PHCs were selected, and in Bihar, 159 PHCs were selected; the PHC physician in clinic on the day of the survey was asked to participate. Verbal consent was obtained to avoid the need to retain individual identifiers. With regard to the pediatricians, an independent random sample of members with a telephone number available was generated for the telephone survey, and then a second sample for whom no telephone number was available plus those with a telephone number available who were not selected for the telephone survey was generated for the mail survey. IAP members without telephone availability could not be randomized to the telephone survey. For both groups, members selected for participation first received a telephone call to solicit their participation using the contact information provided by the IAP office. During this call, persons randomized to the mail survey were asked for their mailing address. Persons in the telephone group were asked if they presently had time to complete the survey, or if there was a convenient time for them to be called back. Persons in the mail group who accepted the invitation to participate were called up to two more times to encourage them to submit their responses. If IAP members in either group were not reachable by telephone, a mail survey was sent with a letter of invitation to the address on file with the IAP office. Persons in both groups received a letter signed by the IAP president thanking them for their participation. Verbal consent was obtained to avoid the need to retain individual identifiers. The Institutional Review Board of Emory University and the Institutional Ethics Committee of Maulana Azad Medical College both determined that this study did not meet the definition of ‘Human Subjects Research’ and was considered ‘Quality Improvement’, and therefore did not need review. 2.4. Instrument
2.2. Formative research PHC physicians were recruited for focus group discussions to provide input on the contents of the survey instrument and to assess the possible utility of data likely to be generated from the survey. The survey instrument developed following the focus group discussion was then pilot tested on PHC physicians in Delhi. Verbal consent was obtained to avoid the need to retain individual identifiers. Following the pilot survey, the number of Likert scale answer options was reduced from five to three. With regard to the pediatricians, focus group discussions were designed to provide input on the contents of the survey instrument and assess the possible utility of data likely to be obtained from the survey. The survey instrument developed following the focus group discussions was then pilot tested on selected pediatricians by telephone and in person. Verbal consent was obtained at the beginning of the focus group and individual identifiers were not retained. Following the pilot surveys the Likert scale answer options were reduced from five to three. 2.3. Surveys PHC physicians in UP and Bihar were surveyed in-person. The primary sampling unit was a block. In most of India a block is a
The survey instrument was designed to assess attitudes and practices associated with routine immunization, vaccine cold chain, polio disease, polio immunization, polio eradication, and barriers to achieving polio eradication. The instrument consisted of 27 questions and took approximately 30 min to complete. Survey items were guided by the Health Belief Model (HBM).10 2.5. Measures The survey assessed the following attitudes and beliefs toward polio and polio immunization on a three-point Likert scale. The questionnaire addressed perceived susceptibility (‘‘How likely do you think a child in India under 5 years of age who has received no vaccine when due is to get the following diseases within the next year?’’; ‘likely’ to ‘not likely’), perceived severity (‘‘If a child under 1 year of age gets the following diseases, how likely is that child to be seriously ill?’’; ‘likely’ to ‘not likely’), perceived vaccine protectiveness (‘‘How protective do you think each of these vaccines is against disease?’’; ‘protective’, ‘somewhat protective’, ‘not very protective’), perceived vaccine safety (‘‘How safe do you think these vaccines are?’’; ‘safe’ to ‘unsafe’), and perceived barriers (‘‘How important are the following barriers to polio eradication?’’; ‘important’ to ‘not important’). Questions assessing attitudes about
<0.0001 148 (62.2) 0.60 80 (64) 68 (60.2) PHC, primary health center; UP, Uttar Pradesh. a Compares states. b Compares PHC physicians and pediatricians with both states combined, adjusted p-value = 0.007.
561 (77.7) 453 (78.0) 108 (76.6)
0.72
150 (63.0) 175 (73.5) 0.81 0.28 80 (64) 96 (76.8) 70 (61.9) 79 (69.9) 593 (82.1) 578 (80.1) 0.98 0.63
p-Valuea UP (581 responses) Bihar (141 responses)
The majority of PHC physicians and pediatricians reported that an unvaccinated child is susceptible to polio (82.1% and 63.0%, respectively) and that the disease is severe in both infants aged under 1 year (80.1% and 73.5%) and in children aged 1–5 years (77.7% and 62.2%) (Table 1). A higher percentage of PHC physicians compared to pediatricians reported that a child under the age of 5 years was likely to become seriously ill if they got polio disease (p < 0.0001) (Table 1). A significantly higher percentage of PHC physicians compared to pediatricians reported that the likelihood of an unvaccinated child getting polio disease was high (p < 0.0001) (Table 1). There were no significant differences in perceived susceptibility among unvaccinated children or severity of polio disease between the respective PHC physicians and pediatricians in each state. Both PHC physicians and pediatricians reported confidence in the protectiveness (PHC physicians 99.0%, pediatricians 76.5%) and safety (PHC physicians 96.8%, pediatricians 91.2%) of the OPV (Table 2). However a higher percentage of pediatricians believed in the protectiveness (84.5%) and safety (88.2%) of inactivated polio vaccine (IPV) than PHC physicians (protectiveness: 83.7%, p = 0.77; safety: 71.3% p < 0.0001). A comparison of the responses of PHC physicians between UP and Bihar indicated that a higher proportion of the PHC physicians in UP felt that IPV was protective (85.9%) compared to PHC physicians in Bihar (protective, 74.5% p = 0.001). There were no significant differences in the responses among pediatricians from UP and Bihar regarding perceptions of polio vaccine protectiveness and safety.
Table 1 PHC physician and pediatrician perceptions of susceptibility to and severity of polio disease
3.2. Comparison of PHC physician and pediatrician perceptions about polio disease and polio vaccine safety
PHC physicians, n (%)
Total (722 responses)
A total of 398 out of 785 surveys (50.7%) were completed in the national survey of pediatricians. Of these surveys, 275 were from UP, of which 125 were completed (45.5%), and 230 were from Bihar, of which 113 were completed (49.1%). In UP, 581 of 614 PHC physicians selected completed the survey (94.6%). In Bihar, 141 of 159 PHC physicians selected completed the survey (88.7%). Overall 93.4% of PHC physician surveys were completed (722 out of 773).
477 (82.1) 463 (79.7)
3.1. Response rate
116 (82.3) 115 (81.6)
3. Results
Likelihood of polio in unvaccinated child Likelihood of becoming seriously ill with polio aged <1 year Likelihood of becoming seriously ill with polio aged between 1 and <5 years
Bihar (113 responses)
Pediatricians, n (%)
Data management and analysis was conducted using SAS version 9.2. Pen-and-paper and telephone survey responses from IAP members were combined. Descriptive analyses were performed to assess the distributions of variables assessing poliorelated attitudes and behaviors among PHC physicians and pediatricians. Chi-square analyses were conducted to assess differences in responses between the two sets of health care professionals in UP and Bihar. For comparisons between PHC and IAP physicians on attitudes and barriers, questions were adjusted for multiple tests using a Bonferroni’s adjustment, which reduced the p-value for significance to 0.007.
UP (125 responses)
2.6. Data analysis
p-Valuea
Total (238 responses)
p-Valueb
polio eradication included ‘‘How likely do you think it is that we will eradicate polio?’’ (‘likely’ to ‘not likely’) and ‘‘How important are the following barriers to polio eradication?’’ (‘important’ to ‘not important’). Questions assessing immunization practices included ‘‘How much time is devoted to polio eradication and other immunization services?’’ by the PHC physicians.
e419 <0.0001 0.26
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Table 2 PHC physician and pediatrician perceptions of polio vaccine protectiveness and safety PHC physicians, n (%)
Protectiveness of oral polio vaccine Protectiveness of inactivated polio vaccine Safety of oral polio vaccine Safety of inactivated polio vaccine
Pediatricians, n (%) a
Bihar (141 responses)
UP (581 responses)
p-Value
138 (97.9)
577 (99.3)
0.28
715 (99.0)
86 (76.1)
105 (74.5)
499 (85.9)
0.001
604 (83.7)
94 (83.2)
136 (96.5)
563 (96.9)
0.76
699 (96.8)
107 (94.7)
91 (64.5)
424 (73.0)
0.05
515 (71.3)
97 (85.8)
Total (722 responses)
Bihar (113 responses)
p-Valuea
Total (238 responses)
p-Valueb
96 (76.8)
0.81
182 (76.5)
<0.0001
107 (85.6)
0.51
201 (84.5)
0.77
110 (88)
0.10
217 (91.2)
0.0007
113 (90.4)
0.20
210 (88.2)
<0.0001
UP (125 responses)
PHC, primary health center; UP, Uttar Pradesh. a Compares states. b Compares PHC physicians and pediatricians with both states combined, adjusted p-value = 0.007.
Table 3 PHC physician and pediatrician perceptions of the importance of eradicating polio and the likelihood of achieving eradication PHC physicians, n (%)
Important to eradicate polio Likelihood of polio being eradicated
Pediatricians, n (%) Total (718 responses)
Bihar (113 responses)
UP (123 responses)
p-Valuea
Total (236 responses)
p-Valueb
0.57
715 (99.6)
113 (100)
123 (100)
0.15
236 (100)
0.65
0.03
671 (93.5)
107 (94.7)
110 (89.4)
0.08
217 (91.9)
0.43
Bihar (137 responses)
UP (581 responses)
p-Value
136 (99.3)
579 (99.7)
122 (89.1)
549 (94.5)
a
PHC, primary health center; UP, Uttar Pradesh. a Compares states. b Compares PHC physicians and pediatricians with both states combined, adjusted p-value = 0.007.
3.3. Comparison of attitudes about polio eradication, barriers to eradication, and strategies for eradication among PHC physicians and pediatricians Nearly all PHC physicians and pediatricians in UP and Bihar believed that it is important to eradicate polio (99.6% and 100%, respectively). In addition, 93.5% of PHC physicians and 91.9% of pediatricians reported that it is very likely that polio will be eradicated (Table 3). Although not significant, more PHC physicians in UP (94.5%) than in Bihar (89.1%) believed that polio will be eradicated (p = 0.03) (Table 3). Parents’ lack of awareness of the importance of polio eradication efforts was the most common reported barrier by both PHC
physicians and pediatricians. More PHC physicians than pediatricians reported a lack of awareness of the importance of polio eradication among parents (94.3% vs. 85.5%, p < 0.0001), lack of confidence in polio vaccine amongst parents (82.0% vs. 69.2%, p < 0.0001), a fear of side effects of polio vaccine amongst parents (75.5% vs. 63.2%, p = 0.0003), and cultural beliefs of parents (64.6% vs. 52.6%, p = 0.001), as important barriers to polio eradication (Table 4). The most common reported barrier by PHC physicians in both UP and Bihar was the lack of awareness of the importance of the polio eradication effort among parents (94.7% and 92.7%, respectively). Significantly more PHC physicians in UP than in Bihar reported parents’ lack of confidence in polio vaccine (84.3% vs. 72.3%, p = 0.001), parents’ religious beliefs regarding polio vaccine (81.2%
Table 4 PHC physician and pediatrician perceptions of the importance of barriers to polio eradication PHC physicians, n (%)
Pediatricians, n (%)
UP p-Valuea Total Bihar UP p-Valuea Total p-Valueb Bihar (718 responses) (113 responses) (121 responses) (234 responses) (137 responses) (581 responses) Parent’s lack of awareness 127 (92.7) of the importance of the polio eradication Parent’s lack of confidence 99 (72.3) in polio vaccine Parents’ religious beliefs 78 (56.9) regarding polio vaccine 85 (62.0) Parent’s fear of side effects of polio vaccine Lack of time or priority 70 (51.1) for parents 70 (51.1) Superstition Parents cultural 66 (48.2) beliefs PHC, primary health center; UP, Uttar Pradesh. a Compares states. b Compares PHC physicians and pediatricians
550 (94.7)
0.38
677 (94.3)
100 (88.5)
100 (82.6)
0.21
200 (85.5)
<0.0001
490 (84.3)
0.001
589 (82.0)
72 (63.7)
90 (74.4)
0.08
162 (69.2)
<0.0001
472 (81.2)
<0.0001
550 (76.6)
73 (64.6)
86 (71.1)
0.29
159 (67.9)
0.008
457 (78.7)
<0.0001
542 (75.5)
72 (63.7)
76 (62.8)
0.89
148 (63.2)
0.0003
416 (71.6)
<0.0001
486 (67.7)
65 (57.5)
71 (58.7)
0.86
136 (58.1)
0.008
407 (70.1) 398 (68.5)
<0.0001 <0.0001
477 (66.4) 464 (64.6)
60 (53.1) 58 (51.3)
73 (60.3) 65 (53.7)
0.27 0.71
133 (56.8) 123 (52.6)
0.008 0.001
with both states combined, adjusted p-value = 0.007.
N/A
PHC, primary health center; UP, Uttar Pradesh; IPV, inactivated polio vaccine; OPV, oral polio vaccine; DTaP, diphtheria–tetanus–acellular pertussis; HBV, hepatitis B virus; N/A, not asked. a Compares states. b Compares PHC physicians and pediatricians with both states combined, adjusted p-value = 0.007.
N/A N/A N/A N/A 337 (46.9) 295 (50.8) 42 (30.4)
<0.0001
N/A N/A N/A N/A N/A 356 (49.5) 0.01 301 (51.8) 55 (39.9)
0.24 <0.0001 <0.0001 <0.0001 N/A 228 (96.6) 178 (75.4) 91 (38.6) 139 (58.9) N/A 0.40 0.15 0.80 0.14 N/A 120 (97.6) 88 (71.5) 54 (43.9) 78 (63.4) N/A 108 (95.6) 90 (79.6) 37 (32.7) 61 (54.0) N/A (94.7) (47.3) (67.3) (76.8) (72.0) 681 340 484 552 518 0.06 0.17 0.04 <0.0001 0.18 (95.5) (48.5) (65.6) (83.1) (73.1)
p-Value UP (581 responses)
555 282 381 483 425 (91.3) (42.0) (74.6) (50) (67.4) 126 58 103 69 93
Total (236 responses) p-Valuea UP (123 responses) Total (719 responses)
Bihar (113 responses)
Pediatricians, n (%)
a
PHC physicians, n (%)
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Strengthening routine immunization Use of mass campaigns with IPV in UP and Bihar Use of mass campaigns with monovalent polio vaccine in UP and Bihar Use of mass campaigns with bivalent polio vaccine in UP and Bihar Trivalent OPV for mass campaigns in UP and Bihar (contains all three polio types, 1, 2, and 3) Use of IPV during routine immunizations, in addition to OPV (such as a schedule of IPV followed by OPV at a separate office visit) If it is used, how important is it that IPV be given as a single vaccine as opposed to a combination vaccine (for example DTaP–IPV or DTaP–IPV–HBV combination vaccine)
The study revealed that PHC physicians in Bihar are devoting more time to immunization activities, including polio, than their counterparts in UP. The percentage of PHC physicians devoting 75– 100% of their time to immunization activities in Bihar was 32.3% vs. only 13.2% in UP. Of the time they are spending on immunization activities, 22.2% of PHC physicians in Bihar are spending 75–100% on planning, supporting, coordinating, and supervising routine immunization services, compared to 5.7% in UP. In Bihar, 27.6% of PHC physicians reported spending 75–100% on planning, supporting, coordinating, and supervising polio-related activities, compared to 5.7% in UP. In Bihar, 19.3% of PHC physicians reported spending 75–100% of their time on data analysis and reporting for routine immunization, compared to 4.3% in UP. Similarly, 19.3% of PHC physicians in Bihar reported spending 75–100% of their time on data analysis and reporting for polio compared to 4.5% of PHC physicians in UP. In their respective states, PHC physicians are devoting almost equal time to both routine immunization and polio vaccination; however, the PHC physicians in Bihar are devoting more time to both routine immunization and polio vaccination than their counterparts in UP.
Bihar (138 responses)
3.4. Practices of PHC physicians regarding polio activities compared to other activities
Table 5 PHC physician and pediatrician perceptions of strategies important for the elimination of polio in endemic areas
vs. 56.9%, p < 0.0001), parents’ fear of side effects (78.7% vs. 62.0%, p < 0.0001), lack of time or priority for parents (71.6% vs. 51.1%, p < 0.0001), superstition (70.1% vs. 51.1%, p < 0.0001), and parents’ cultural beliefs (68.5% vs. 48.2%, p < 0.0001) as barriers to eradication (Table 4). In contrast, there was no difference in reported barriers by pediatricians from UP and Bihar. When asked to list the two most important barriers to polio eradication, ‘‘Parents’ lack of awareness of the importance of polio eradication’’ was the most significant barrier among both groups: PHC physicians (57.0%) and pediatricians (54.0%). This barrier was listed as most important among respondents from both Bihar (PHC physicians 67.8% and pediatricians 54.5%) and UP (PHC physicians 51.8% and pediatricians 55.3%). However, PHC physicians and pediatricians differed with regard to the perception of the second most important barrier: ‘‘Parents’ fear of side effects of polio vaccine’’ was the perceived reason among PHC physicians (23.2%), whereas pediatricians believed ‘‘Parents’ religious beliefs regarding polio vaccine’’ was the second most important reason (21.4%). A high percentage of PHC physicians (94.7%) and pediatricians (96.6%) in the two states reported that strengthening routine immunization is an important strategy for eliminating polio in endemic areas. The PHC physicians were more supportive than pediatricians of mass campaigns with monovalent oral polio vaccine (mOPV) in UP and Bihar (67.3% and 38.6%, respectively, p < 0.0001) and mass campaigns with bivalent oral polio vaccine (bOPV) in UP and Bihar (76.8% and 58.9%, respectively, p < 0.0001) (Table 5). On the other hand, pediatricians were more supportive than PHC physicians of mass campaigns with IPV in UP and Bihar (75.4% and 47.3%, respectively, p < 0.0001). The PHC physicians in Bihar were more supportive of mass campaigns using mOPV in UP and Bihar than PHC physicians in UP (74.6% and 65.6%, respectively, p = 0.04). The PHC physicians in UP were significantly more supportive of mass campaigns using bOPV in UP and Bihar than PHC physicians in Bihar (83.1% and 50%, p < 0.0001). PHC physicians in UP were also more supportive than PHC physicians in Bihar of strategies that included the use of IPV during routine immunization, in addition to OPV (51.8% and 39.9%, respectively, p = 0.01). Also, a higher percentage of PHC physicians in UP than in Bihar felt it would be important that IPV be given as a single vaccine as opposed to a combination vaccine (50.8% and 30.4%, respectively, p < 0.0001) (Table 5).
p-Valueb
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In response to the question ‘‘What would they devote their time to if they did not have to do SIAs [supplementary immunization activities] for polio?’’, a majority of PHC physicians in UP mentioned that they would devote their time to clinical work, followed by routine immunization, while in Bihar PHC physicians reported that they would prefer to devote more time to routine immunization, followed by clinical work. 4. Discussion Our data show that polio eradication efforts continue to have strong support from PHC physicians and pediatricians in high-risk states. Continued support of the medical profession is critically important so that there is no complacency among key opinion leaders in these efforts. Importantly, 92% of pediatricians and 94% of PHC physicians believe that polio will be eradicated. This belief is relatively stronger among PHC physicians in Bihar and pediatricians in UP. As physicians have influence on policy-makers and the public in their communities, it may be important to further increase their confidence in the eradication of polio. The results of this survey show that the majority of these physicians from UP and Bihar perceive that an unvaccinated child is susceptible to polio and that infants and children are likely to develop severe disease if they get polio. However, PHC physicians were generally more concerned than pediatricians about the likelihood of polio and its severity in young unvaccinated children. This observation was similar in both UP and Bihar. Physician perceptions of the protectiveness and safety of the polio vaccine are important in motivating physicians to encourage parents to have their child vaccinated, in order to achieve high immunization coverage, and are very relevant for polio eradication efforts. In India OPV has been used as the primary eradication strategy, and most countries in the world have achieved polio eradication using only OPV. The IPV has recently been licensed in the country and is being used in the private sector on a limited scale.11 Whether IPV should be used in the public sector for intensifying polio eradication efforts has been debated.12,13 This study shows that physicians in general consider both OPV and IPV to be protective and safe. Pediatricians were convinced of the protectiveness of OPV, but in comparison with PHC physicians, they had slightly more faith in the efficacy of IPV. This could be due to the fact that IPV is being used primarily by pediatricians in the private sector who are therefore more familiar with it. As the confidence of physicians in polio vaccines is important in building and maintaining the trust of parents, these survey results could positively influence polio eradication efforts. Physician perceptions of barriers to polio eradication are very important, as they are in close contact with the community. Though several barriers were identified, parents’ perceived lack of awareness of the importance of polio eradication and parents’ perceived lack of confidence in polio vaccine stand out as the most important. Interestingly, PHC physicians believed these barriers to be more serious than pediatricians. This survey also tried to determine the relative importance of the two most important barriers identified by PHC physicians and pediatricians. While parents’ perceived lack of awareness about the importance of polio continues to be the main factor in both states, there were some interesting differences identified for the second factor. For pediatricians in UP, this was lack of confidence in polio vaccine, while in Bihar it was parents’ religious beliefs regarding polio vaccine. For PHC physicians in UP, superstition was cited as the second most important barrier, while in Bihar it was fear of side effects of polio vaccine. Intensive polio immunization campaigns with trivalent OPV have proved successful for the elimination of polio virus in Indian states other than UP and Bihar.14 The resurgence of polio cases in
2002 and again in 2006–07 in these two states led to serious setbacks in national polio eradication efforts.15,16 This led to the introduction of new technical strategies and innovations in the program, including the use of monovalent vaccines and recently the use of bivalent vaccine.17,18 There has been an ongoing debate about the use of IPV in the program in recent years.19 PHC physicians and pediatricians in UP and Bihar strongly supported routine immunization as an important strategy for eradicating polio. Mass campaigns were also considered an important strategy for polio eradication; however, PHC physicians and pediatricians differed on the type of polio vaccines that should be used in mass campaigns. PHC physicians have more faith in mOPV and bOPV, while pediatricians feel that IPV is more appropriate. The lack of support for bOPV among PHC physicians from Bihar (50%) is a matter of concern, as bOPV has recently been the most important tool responsible for the success of the Global Poliomyelitis Eradication Initiative in these two endemic states.3 This may have been due to the timing of the study; bOPV was introduced in India in January 2010 while this survey was conducted between June 2009 and June 2010, and the impact of bOPV was not evident while this study was being conducted. Regarding the use of IPV during routine immunization in addition to OPV, PHC physicians from UP were more supportive than their counterparts in Bihar. PHC physicians in UP would prefer to use IPV as a single vaccine rather than a combination vaccine if it were used in the program.17 These findings should be of great interest to policy-makers and planners when consideration is given to modifying the type of vaccine to be used during the end stages of eradication or in the post-eradication phase. It is very important to instill confidence in the polio eradication program in both providers and parents if polio transmission is to be interrupted in the near future. 4.1. Limitations The national survey that provided the pediatrician data was cross-sectional in nature, and 49% of pediatricians selected did not complete the survey despite multiple follow-up attempts; this may have resulted in some response bias. The PHC physician surveys were done in-person, which may have resulted in a social desirability bias in their responses. Although confidentiality and anonymity of the respondents were maintained, there is a possibility that respondents may have overestimated their compliance with and support of recommendations from the IAP or the government.
5. Conclusions The findings of the current study provide reassurance that there is a very high level of support for polio eradication activities among both PHC physicians and pediatricians, the two key health care providers for children in India. Polio-related immunization is still accorded very high priority among health care professionals in India. They are confident that polio will be eradicated from India very soon. They have a high level of confidence in the safety and protective efficacy of both OPVs and IPV. Both PHC physicians and pediatricians are unanimous in advocating the strengthening of routine immunization efforts as one of the important strategies for the elimination of polio in endemic areas, in addition to mass campaigns. The study also provides a glimpse of a few important barriers that need to be addressed urgently in order to achieve high immunization rates in the two highly endemic states. These findings should be of great interest to policy-makers and planners in considering the need for modifications to polio eradication strategies to achieve rapid interruption of wild virus transmission and to sustain eradication once it is achieved.
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Acknowledgements We would like to thank our survey participants, Dianne Miller and Ashley Freeman at Emory University for their administrative support, the Executive Board members of IAP, and the staff of St. Stephens Hospital, especially Vipin Gupta. We also thank Surveillance Medical Officers at the National Polio Surveillance Project (NPSP) and the governments of Uttar Pradesh and Bihar for their support of the project. This work was supported by grant #50230 from the Bill and Melinda Gates Foundation. Conflict of interest: The authors have no financial or personal relationships to disclose. References 1. World Health Organization. Polio eradication. Geneva: WHO; 2012. Available at: http://www.who.int/trade/distance_learning/gpgh/gpgh2/en/index3.html (accessed February 2012). 2. World Health Organization. Global Polio Eradication Initiative: annual report 2007–2008. Geneva: WHO; 2009. 3. Centers for Disease Control and Prevention. Progress toward interruption of wild poliovirus transmission—worldwide, January 2010–March 2011. MMWR Morb Mortal Wkly Rep 2011;60:582–6. 4. Paul Y. Why polio has not been eradicated in India despite many remedial interventions? Vaccine 2009;27:3700–3. 5. United Nations Children’s Fund (UNICEF). Coverage evaluation survey report 2009. New Delhi: UNICEF; 2009. Available at: http://www.unicef.org/india/1__CES_2009_All_India_Report.pdf (accessed September 12, 2011).
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