immunisation attitudes, knowledge and practices of health professionals in regional nsw

224 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2008 vol. 32 no. 3© 2008 The Authors. Journal Compilation © 2008 Public Health Association of Australia

Immunisation attitudes, knowledge and practices of

health professionals in regional NSW

Julie LeaskNational Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases (NCIRS), The Children’s Hospital at Westmead and the Discipline of Paediatrics and Child Health, University of Sydney, New South Wales

Helen E. QuinnNational Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases (NCIRS), The Children’s Hospital at Westmead and the University of Sydney, New South Wales

Kristine MacartneyNational Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases (NCIRS), Department of Infectious Diseases and Microbiology, The Children’s Hospital at Westmead and the University of Sydney, New South Wales

Marianne TrentNorth Coast Population Health, New South Wales

Peter Massey and Chris CarrHunter New England Population Health, New South Wales

John TurahuiNorth Coast Population Health, New South Wales

Abstract

Objective: This study investigated the

immunisation knowledge, attitudes and

practices among health professionals in

two regional Area Health Services of NSW

with low and high immunisation rates. It also

compared these factors between the areas

and between the health professional groups.

Methods: A self-administered

questionnaire was posted in 2006 to

health professionals, located within the

North Coast and Hunter New England

Area Health Services, whose practice

could include immunisation. This included

general practitioners (GPs), practice

nurses, community nurses, hospital nurses

and midwives.

Results: Out of 926 surveys sent, 434

were returned (47%). The great majority

of the health professionals (97%) believed

that vaccines were safe, effective and

necessary. However, in approximately one-

third of respondents, there were specific

concerns about additives, immune system

overload and the number of vaccines.

Significantly more health professionals in

the North Coast area believed that additives

in vaccines may be harmful and that adding

more vaccines to the schedule would make

immunisation too complex. Among GPs,

over half felt uncomfortable about giving

more than two injections at the one visit.

Conclusions: Health professionals in this

study had overall confidence in vaccines

but had specific concerns about the number

of vaccines given to children and vaccine

content. These unfounded concerns may

reduce parental confidence in immunisation.

Implications: There is value in

governments and immunisation support

workers continuing their efforts to maintain

up-to-date knowledge among health

professionals and support the delivery of

appropriate and targeted information to

address concerns about vaccines.

Keywords: Health Care Surveys;

Health Knowledge, Attitudes, Practice;

Vaccination; Australia; Health Personnel;

Measles-Mumps-Rubella Vaccine

Aust N Z Public Health. 2008; 32:224-9

doi: 10.1111/j.1753-6405.2008.00220.x

Submitted: September 2007 Revision requested: January 2008 Accepted: March 2008Correspondence to: J. Leask, NCIRS, The Children’s Hospital at Westmead, University of Sydney, Locked Bag 4001, Westmead NSW 2145, Australia. Fax: (02) 9845 1418; e-mail: JulieL3@chw.edu.au

Australia currently enjoys high

immunisation rates with 94% of

2-year-old being fully vaccinated.1

Most vaccines for children are publicly

funded and provided free at point of care

under the National Immunisation Program

(NIP), and vaccine coverage is recorded

and reported by the national population-

based Australian Childhood Immunisation

Register (ACIR). Despite high vaccination

rates, pockets of opposition to vaccination

exist in some communities in Australia,

where lower coverage rates are known to

occur. Communities with low vaccination

coverage experience outbreaks of vaccine-

preventable diseases.2

Concerns about vaccine safety significantly

contribute to under-immunisation of

children. A 2001 Australian study found

that 58% of parents of children not up-to-

date for immunisation cited disagreement or

concerns about immunisation as their main

reason.3 For advice regarding the safety of

vaccines, parents look foremost to health

professionals.4-6 Therefore, it is essential

that health professionals are equipped to

respond confidently to a wide range of

parental concerns. Instances where health

professional confidence in immunisation

safety has declined have been followed by

major reductions in immunisation rates.7

Few studies have compared attitudes

between health professionals in areas of low

and high immunisation rates. This study

Infants and Children Article

2008 vol. 32 no. 3 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 225© 2008 The Authors. Journal Compilation © 2008 Public Health Association of Australia

aimed to describe differences in attitudes between two regional

areas in New South Wales (NSW) where, in 2005, immunisation

coverage rates by two years of age differed at 86% for the North

Coast (NC) and 93% for the Hunter New England (HNE).8

The second aim of the study was to identify the immunisation

knowledge, attitudes and practices among health professionals

who provide immunisation in regional NSW, with a focus on

differences between professional groups. The goal was to improve

the existing support of health professionals and ultimately to find

targeted ways to improve immunisation rates, particularly in areas

with sub-optimal coverage.

A particular focus of this study was to examine beliefs about the

safety of the MMR vaccine in the light of an alleged but unfounded

link to inflammatory bowel disease and autism, and evidence of the

impact of this concern on UK health professionals.9,10 In addition,

we examined the impact that the changes to the immunisation

schedule prior to the survey had had on health professionals. This

included the introduction of new vaccines and many schedule

changes. Meningococcal C and pneumococcal conjugate vaccines

and varicella zoster vaccines were recommended as part of the

schedule but, for a time, not funded under the NIP.11 A funded

program for hepatitis B vaccination of all neonates, rather than just

those at risk, also commenced. With this change, midwives became

the first provider of immunisation to infants. As a relatively new

immunisation provider in Australia, our study sought information

on the extent of midwives’ concerns about vaccine safety.

MethodsData collection

The study was an anonymous self-completed postal survey of

immunisation health professionals from the Hunter New England

and North Coast Area Health Services (AHS) in NSW. The target

population for the survey was health care providers involved in

immunisation. This included general practitioners (GP), practice

nurses (PN), early childhood nurses, generalist community nurses,

midwives, and hospital nurses from paediatrics wards, neonatal

intensive care and emergency departments. Approval was gained

from the Hunter, New England, and the North Coast Area Research

Ethics Committees.

Survey developmentA range of data informed development of the survey including

the findings of previous studies and the in-depth knowledge of local

immunisation coordinators (MT, CC, JT, PM).10,12-14 Many of the

questions were adapted from a 2002 unpublished survey of health

care workers in Western Sydney, NSW and a 1998 survey of health

professionals in Quebec, Canada.15,16 The survey was pre-tested with

a sub-sample of 11 health professionals from each AHS.

The survey covered five major areas:

1. Knowledge regarding vaccine contraindications.

2. Beliefs and attitudes about safety and necessity of certain

vaccines.

3. Practices in recommending unfunded vaccines.

4. Practices in communicating with parents about

immunisation.

5. Resources currently utilised.

Sampling procedurePrevious research in Western Sydney indicated that, in an area of

high vaccine coverage, such as the Hunter New England, 95% of health

professionals would be supportive of immunisation.15 We assessed

that if only 88% of health professionals in the North Coast were to

support immunisation, this 7% difference may influence coverage.

To detect this difference with 80% power at a significance level of

0.05, 248 health professionals were required from each area. The

sampling procedure involved stratifying by each AHS and sampling

each health professional group proportionally to the population

distribution of all health professionals within that area. The exception

to this was midwives, who were ‘over sampled’ in each area to allow

precise estimates for this group alone. After taking into account

likely response rates, 507 health professionals from the NC and 419

health professionals from HNE were mailed the questionnaire. For

each health professional group, participants were randomly selected

from records kept by public health units. Surveys were sent in April

2006 with a follow-up mailout to non-respondents.

Data analysisCompleted questionnaires were reviewed and information

entered into an EpiInfo database. Data cleaning, recoding and

statistical analysis were performed using SAS v9.1.3. Samples were

weighted to take into account non-response and disproportionate

sampling of health professionals from each AHS. Where possible,

response variables, including 5 point Likert scales for agreement,

were collapsed into dichotomous variables. Unless otherwise

stated, those reporting ‘agree strongly’ or ‘agree somewhat’

were recoded as ‘agree’ and compared with all others (including

‘disagree strongly’, ‘disagree somewhat’ and ‘unsure’). Where

results for early childhood nurses and generalist community nurses

were combined a new group was named ‘Community Nurses’.

Point estimates and 95% confidence intervals (CI) were

calculated where appropriate. When comparing the two areas,

point estimates and confidence intervals were used to determine

signif icance. Non-overlapping conf idence intervals were

considered significant. When comparing dichotomous variables,

an odds ratio was calculated and a chi square test used to assess

statistical significance. A p value less than 0.05 was considered

statistically significant. Content analysis was performed on text

responses and included grouping answers into common themes.

ResultsOf 926 surveys sent, 427 were returned completed (47%).

Response rates to the survey varied between the AHS and health

professionals (Table 1). In comparison with population data on

GPs, our survey over-represented females (43% this study versus

33% NSW medical workforce census data).17

Infants and children Immunisation attitudes of health professionals

226 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2008 vol. 32 no. 3© 2008 The Authors. Journal Compilation © 2008 Public Health Association of Australia

Immunisation attitudes Childhood vaccines in the National Immunisation Program at

the time of the survey were considered to be safe by 414 of the 427

respondents (97%), effective by 416 (98%) and necessary by 409

(96%). No significant difference was found between HNE and NC

areas. Table 2 shows these findings by professional group.

Respondents rated their level of agreement with a number of

commonly held concerns about vaccines (Figure 1). Significant

proportions agreed that children get too many vaccines in the

first two years of life. Consistently more health professionals in

the NC area compared with HNE agreed with these statements

of concern; however, these differences were only statistically

significant regarding the statement that additives in vaccines may

be harmful (23%, [95% CI: 16.9-28.7%] versus 10%, [95% CI:

6.3-14.0%]). When examining these results by health professional

category, hospital nurses were more likely to agree or be unsure

about all the statements than those in general practice. In addition,

midwives were significantly more likely than all other respondents

to agree that the additives in vaccines may be harmful (53% versus

36% [OR: 2.0, 95% CI: 1.3-3.0]) and that concurrent immunisation

might overload the immune system (56% versus 28% [OR: 3.3,

95% CI 2.1-5.1].

Respondents were asked about the importance of vaccinating

young children against specific diseases. Vaccination against polio

was most strongly supported (95% agreed completely) followed

by pertussis (94%), measles (92%), pneumococcal disease (85%),

hepatitis B (84%), meningococcal type C disease (80%), and

varicella (79%).

When examining the attitudes of specific health professionals,

both early childhood nurses and practice nurses were significantly

more likely than GPs to agree completely about the importance

of vaccinating young children against varicella (early childhood

nurses 94% versus GPs 73% [OR: 5.7, 95% CI: 1.2-26.1] and

practice nurses 89% versus GPs 73% [OR: 3.0, 95% CI: 1.4-6.6]).

Similarly, practice nurses were significantly more likely than GPs

to agree completely about the importance of vaccinating young

children against meningococcal C (PNs 98% versus GPs 77% [OR:

2.4, 95% CI: 1.1-5.3]) and hepatitis B (PNs 92% versus GPs 80%

[OR: 3.0, 95% CI: 1.2-7.4]).

There was general support for the neonatal hepatitis B vaccine

for newborns with overall 83% agreeing it was necessary and 85%

agreeing it was safe. While 88% of midwives felt the vaccine was

necessary, slightly fewer (81%) believed it was safe and 35% felt

it was given too young. GPs had the least support for the vaccine,

with only 77% believing the newborn dose to be necessary for

disease control.

Immunisation knowledge and beliefsWith regard to true and false contraindications to vaccination,

based on the NHMRC Australian Immunisation Handbook 8th

edition, the majority of GPs and PNs correctly believed that

vaccines could still be given with antibiotic use (86%); temperature

of 37°C and runny nose (90%); family history of convulsions

(87%); and child’s mother being pregnant (89%); and should

not be given when the child had a temperature of 38°C and felt

unwell (95%). There were no significant differences in these

results between areas.

Table 3 shows beliefs about an association between MMR

vaccine, inflammatory bowel disease and autism. Only 59% of

respondents believed there was no association, with little difference

between the two areas. Overall, hospital nurses and midwives had

Table 1: Survey response rates by area and health professional category.

Complete Surveys sent Rate %Area response ratesHunter New England 221 419 53

North Coast 213 507 42

Health professional group response ratesGeneral Practitioner 95 260 37

Practice Nurse 81 136 60

Early Childhood Nurses 30 45 67

Generalist Community Nurses 40 69 58

Hospital Nurses 76 141 54

Midwives 112 275 41

Table 2: Proportions of health professionals in regional NSW agreeing that childhood vaccines are safe, effective and necessary.

%a

Health professionalb Safe Effective Necessary

Practice Nurse n=81 100 100 97

General Practitioner n=95 100 97 97

Hospital Nurses n=74 97 92 97

Generalist Community Nurses n=39 96 96 96

Early Childhood Nurses n=30 94 91 98

Midwives n=109 92 98 93

OVERALL 97 98 96

Notes:(a) Weighted percentages (b) Total for each group vary due to missing data

0% 20% 40% 60% 80% 100%

Complementary health practicesreduce need for immunisation

Good eating habits/healthy lifestylereduce need for immunisation

Children get too many vaccines inthe first two years of life

Concurrent immunisation mightoverload immune system

Additives in vaccines may be harmful

AgreeUnsureDisagree

Figure 1: Proportion of NSW regional health professionals who agree with, are unsure about, or disagree with specific statements about vaccination.

Leask et al. Article

2008 vol. 32 no. 3 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 227© 2008 The Authors. Journal Compilation © 2008 Public Health Association of Australia

the most uncertainty with 57% and 40% respectively, being unsure.

Community nurses were the group most likely to believe in an

association with 21% responding “yes”. Of all respondents, only

7% correctly answered that there was an association between

MMR vaccine and a rare bleeding disorder, thombocytopenic

purpura, despite the established link being listed in the Australian

Immunisation Handbook 8th edition.11

Responding to concerned parents and conscientious objectors

Respondents were given a list of all current vaccines on the

schedule and asked which ones raised the most questions and

concerns from parents and what these concerns were. Of the

eight vaccines listed (Table 4), respondents noted the MMR

vaccine as most frequently raised by parents, with the majority

of concerns about a link to autism. For hepatitis B vaccine, the

most commonly reported questions were about necessity and the

view that the vaccine was given “too young”. The question of

vaccine necessity was the most commonly reported issue regarding

varicella, pneumococcal and polio vaccines.

In their discussions with parents, most respondents felt confident

answering questions about immunisation. Community nurses

reported significantly more confidence (99%) than hospital

nurses and midwives combined (77%) [OR: 23.0, 95% CI 3.6-

146.7]. GPs and PNs combined also reported significantly more

confidence than hospital nurses and midwives combined (91%)

[OR: 3.2, 95% CI 1.7-5.8]. When parents refused immunisation

for their child, only 2% of GPs would refuse to treat the child

in the future and 18% would never sign the form required by

vaccination conscientious objectors to receive government family

assistance payments.

The vaccine scheduleOne-third of all respondents felt that adding more vaccines to

the schedule would make immunisation too complex for health

professionals. This was reported significantly less often in HNE

(28%, 95% CI: 22-34%) when compared with NC (43%, 95%

CI: 36-50%).

GPs and PNs were asked about their practices and feelings about

giving more than two injections at the one visit. The majority said

they would give more than two injections if needed (89% for GPs

and 91% for PNs), but almost half (46%) of all GPs and one-third

(35%) of PNs reported feeling uncomfortable doing so.

During the time that certain vaccines were recommended as

part of the Australian Standard Vaccination Schedule but were not

publicly funded under the National Immunisation Program, only

around half of all GPs would “mostly or always” recommend them

(meningococcal C vaccine [57%], pneumococcal vaccine [46%],

and varicella vaccine [47%]).

Use of resourcesThe utilisation of immunisation resources is shown in Figure 2.

The Australian Immunisation Handbook 8th edition in hardcopy

was rated as useful by 93% of health professionals, while the

accompanying CD and online version were less often reported

as useful. The second most useful resource was a booklet

for consumers, Understanding Childhood Immunisation and

telephone advice from the public health unit (PHU), whereas

websites were the least used resource.

When examining the popularity of resources by health

professional group, 94% of GPs and 95% of PNs found newsletters

from Divisions of General Practice (DGP) a useful source of

information on immunisation. Between 86% and 100% of

community nurses found the local immunisation coordinator, PHU

telephone advice, and the Understanding Childhood Immunisation

booklet useful.

Continuing educationThe highest rate of accreditation training occurred among

community nurses, with 93% reporting having undergone or

undergoing the immunisation accreditation course. This was

followed by practice nurses (69%), midwives (39%) and hospital

nurses (26%). Nurses who received accreditation training

Table 3: Beliefs about MMR vaccine among NSW regional health professionals.

%a

Inflammatory Autism Idiopathic bowel thrombocytopenic disease purpura

Beliefs about an yes 17 12 7

association between MMR unsure 37 29 45

vaccine and each condition no 59 59 48

Note:(a) Weighted percentages

Table 4: Specific vaccine concerns or questions raised by parents according to NSW regional health professionals.

Childhood vaccine Number of respondents raised by parent nominating concerns about vaccine raised by parents

MMR 174

Hepatitis B 133

Varicella 94

Meningococcal C 73

DTPa 52

Pneumococcal conjugate 33

Polio 21

Hib 10

Infants and children Immunisation attitudes of health professionals

228 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2008 vol. 32 no. 3© 2008 The Authors. Journal Compilation © 2008 Public Health Association of Australia

reported significantly more confidence in answering parental

questions about immunisation (p<0.001), compared with nurses

who did not receive such training. They were also more likely

to answer correctly that a family history of convulsions was not

a contraindication to vaccination (p<0.001) but were not more

likely to believe that immunisation was safe, effective or necessary

(p=0.16, p=0.10 and p= 0.44, respectively).

While GPs wanted more workshops and/or seminars (43%),

inservice and/or updates were the most popular form of continuing

education for PNs (58%), community nurses (51%), midwives

(74%) and hospital nurses (70%).

DiscussionIn this study, health professionals in the region with relatively

low immunisation rates (North Coast) were slightly but consistently

less confident in vaccine safety compared to the region with higher

immunisation rates (Hunter New England). While it is possible the

differences in confidence levels may partly explain the differences

in immunisation coverage, other differences between the areas may

also contribute, including transience, and social and economic

disadvantage, in addition to health care utilisation and access. The

slight attitudinal differences between areas indicate that health

professionals are situated in their community contexts and both

reflect and influence community opinion about immunisation.

Indeed, an overall figure of 3% of health professionals in this

study disagreed that vaccines on the ASVS were safe and this is

the same small but significant proportion of parents who actively

refuse immunisation in Australia.3

With respect to the study’s overall findings on attitudes, the vast

majority of health professionals felt vaccines to be safe, effective and

necessary. However, despite these attitudes, a significant proportion

held unwarranted concerns about the content, timing and number of

vaccines given to children, and a smaller proportion believed that

there were suitable alternatives to vaccination. These findings are

similar to a previous study of health professionals in Western Sydney

and to those of studies with parents.6,15 Overall, health professionals

tended to have greater support for older, more established vaccines,

again similar to studies of parents.18,19 GP respondents, in particular,

had limited support for the varicella vaccine which could indicate

the need for further education about program rationale.

While studies have repeatedly failed to confirm a link between

MMR vaccine, inflammatory bowel disease and autism, our study

found a number of health professionals are still unsure about the

association.20 That the majority were unaware of an established link

between MMR vaccine and thrombocytopenic purpura demonstrated

a lack of factual knowledge, or easy access to factual knowledge,

a finding consistent with a similar UK study.10 This may indicate

a propensity for ongoing media coverage to influence their beliefs

and highlights the need for continued education. In addition, timely

and targeted information would be of value for health professionals

when the media raises their concerns and those of parents.21

The views of midwives regarding vaccination are important. As the

health professionals now at the first vaccine encounter for parents,

there is the potential for midwives’ attitudes to have an impact on

parent vaccine acceptance throughout the rest of childhood. Also,

completion of the hepatitis B vaccination series is more likely

among those receiving the first dose at birth.22 Midwives in this study

had overall confidence in the neonatal hepatitis B vaccine’s safety,

although more than one-third believed that the vaccine was given

too young. In addition, their concern about concurrent immunisation

has implications for how midwives would support additions to the

infant schedule. Given the low response rate among midwives, further

research is needed to determine the extent of such views.

Our study indicated good levels of knowledge about vaccine

contraindications and indicated an improvement in knowledge

since Herceg et al.’s survey in 1997.13 The persistence of the belief

that a family history of convulsions contraindicated vaccination

is likely to be a lingering effect of the disquiet over the safety of

the no-longer used whole cell pertussis vaccine.23

A recent study found that immunisation providers in general

practice are delaying the meningococcal C vaccination at 12

months of age, possibly to avoid giving three injections at the one

visit.24 Our finding that nearly a half of GPs were uncomfortable

giving more than two injections at the one visit indicates where

some of this delay might originate, although the preferences of

parents will also be a factor.14

This study is limited due to the low GP response rate but it

has raised an important area for closer consideration: while the

introduction of multivalent vaccines, particularly in the first year

of life, has the potential to alleviate this problem temporarily, new

vaccines in the pipeline may make multiple injections a persistent

issue for health professionals.

The existence of recommendations for the use of vaccines not

funded under the NIP showed that vaccine funding significantly

affects the propensity for a GP to suggest vaccine/s to a child.

The anticipated availability of new vaccines is likely to continue

to challenge policy makers, funding mechanisms, and health

professionals in this regard.

to “Public Health Unit telephone advice” for clarity.

0 20 40 60 80 100

Australian Immunisation Handbook

Handbook CD/Online

Myths and Realities

Understanding ChildhoodImmunisation

Division of General Practicenewsletters

Local immunisation coordinator

Public Health Unit telephone advice

Pharmaceutical company

Websites

%

UsefulNot usefulUnawareDid not answer

Figure 2: Usefulness of immunisation information proportions as reported by NSW regional health professionals.

Leask et al. Article

2008 vol. 32 no. 3 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 229© 2008 The Authors. Journal Compilation © 2008 Public Health Association of Australia

The Australian Immunisation Handbook continues to be the

most important resource for health professionals. However, this

survey shows that local support workers, such as immunisation

coordinators, public health units and divisions of general practice,

are an important conduit for, and source of, information. In addition,

immunisation accreditation training for nurses improved knowledge

about one contraindication and confidence in addressing parents’

concerns but did not change attitudes to vaccination.

While this study had adequate response rates for nurses, there

was a low response rate among GPs and midwives. This limits

the extent to which the findings for these professionals can be

generalised and further information is needed. It is possible that

non-respondents were less engaged with, or less supportive of,

immunisation. Hence, this study may over-estimate confidence

in vaccines. However, a previous study with high response rates

indicated similar findings.15 Our study may also have limited

generalisability to other Australian health professionals involved in

immunisation, as it was undertaken in regional NSW. Application

of these study methods to other areas is currently occurring.

ImplicationsHealth professionals influence parents to immunise or

not immunise their children.4-6,25 Therefore, there is value in

governments and immunisation support workers continuing their

efforts to maintain up-to-date knowledge and support the delivery

of targeted information to health professionals.

Current investment in the dissemination of recommendations

via avenues such as the Australian Immunisation Handbook and

local support personnel should continue. The introduction of more

vaccines to the childhood schedule will continue to challenge

health professionals in terms of coverage and complexity. This

impact needs to be considered in making decisions about future

vaccine programs.

As vaccine-preventable diseases have become less common in

Australia, the focus increasingly has moved to vaccine safety and

necessity. Increased effort in ensuring health professionals are

better informed about the benefits and safety of immunisation and

are kept up-to-date with changes will help to maintain the currently

high immunisation coverage needed to protect Australians against

potentially serious vaccine-preventable diseases.

AcknowledgementsWe are grateful to Glenda Lawrence, Nick Wood, Sean Gibney,

Peter Eisenberg and Sue Campbell-Lloyd who provided input into

the survey content, Christine Staples, Penny Cox and Kylie Parsons

who assisted in survey mailouts, Melissa Helferty who undertook

data entry and cleaning, Cornelis Biesheuvel and Jennifer Peat who

provided statistical advice, and four peer reviewers who provided

helpful feedback.

NCIRS is supported by The Australian Government Department

of Health and Ageing, The NSW Department of Health and The

Children’s Hospital at Westmead.

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Infants and children Immunisation attitudes of health professionals