Knowledge, Attitude and Perception Towards Adult Vaccination Among Outpatient Department Attendees in a Tertiary Care Centre: A Cross-Sectional Study.

Vaccination is still one of the most effective public health interventions, preventing morbidity, disability and millions of deaths worldwide every year.1,2 Although childhood immunization programs in many countries including India have achieved tremendous coverage, adult vaccination still receives less attention.3 However, several vaccine-preventable diseases (VPDs) are still relevant among adults due to waning immunity, comorbidities, occupational exposure risks and increased life expectancy.4 Despite national and international recommendations, uptake of adult vaccines, including influenza, pneumococcal, hepatitis B, HPV, and tetanus boosters, remains low across low- and middle-income countries (LMICs).5,4

 

Vaccine hesitancy has been identified by the World Health Organization (WHO) as one of the ten top threats to global health, driven by confidence deficits, complacency, and convenience-related barriers.6 Studies demonstrate that lack of awareness, misinformation spread via social media, cultural beliefs, and low risk perception are significant influences on adult vaccination behaviour.7,8 In India, the lack of national adult immunization policy leads to inconsistent practices, poor patient–provider communication, and a lack of clarity about health-seeking behaviour.9

The outpatient departments (OPDs) of tertiary care hospitals are the ideal platforms for adult vaccine education. Patients and caregivers visiting OPDs often have chronic conditions or age-related vulnerabilities that increase their susceptibility to vaccine-preventable complications.10 However, evidence suggests that healthcare workers often fail to adequately counsel adults about immunizations due to time constraints, inadequate training, or the misconception that vaccines are for children only.11 Counseling at the point of care can make a big difference for vaccine acceptance, and provider recommendations can have a powerful effect on adult immunization, as shown in studies from around the world.12,13

 

Thus, understanding knowledge, attitude, and perceptions (KAP) of adults is important for designing effective interventions to improve vaccine uptake. The present study was conducted to assess the KAP of adult vaccination among OPD attendees in a tertiary care centre in India and to assess the impact of brief counselling on improving awareness and acceptance.

This cross-sectional study was conducted in the Outpatient Department of Mahatma Gandhi Medical College and Hospital (MGMCH), Jaipur. A total of 150 adult participants were recruited through convenience sampling. The patients and caregivers who were 18 years or older and attended the OPD were invited to participate after obtaining informed consent. Sociodemographic data, vaccination history, knowledge, attitudes, perceptions and barriers to adult vaccination were collected using a structured pre-validated questionnaire. Approval of the Institutional Ethics Committee was obtained for the study.

 

The data collection was conducted in two stages. To begin, participants completed the pre-counseling questionnaire to gauge their knowledge and perceptions at baseline. Then, a short-structured counseling session was done on the importance of adult vaccination, recommended vaccines, safety and availability. Participants completed a post-counseling assessment immediately after counseling to assess change in awareness and willingness to vaccinate. The data were entered into Microsoft Excel and analyzed using SPSS version 23. Descriptive statistics (frequencies, percentages, means, standard deviations) were computed and associations were tested with the Chi-square test. Statistical significance was accepted at p-value < 0.05.

Sociodemographic Characteristics

The study included a total of 150 participants. The mean age was 40.1 years; 95 (63.3%) females and 55 (36.7%) males. Fifty percent (n = 75) of the respondents were from urban areas and the remaining 50% (n = 75) were from rural areas. The educational status was mixed with 30 (20%) had primary education, 54 (36%) having secondary education and 66 (44%) being graduates and above.

 

Table 1. Sociodemographic characteristics of participants (n = 150)

 

A total of 120 participants (80%) reported that they had received at least one adult vaccine. The most common vaccination was COVID-19 (108, 90%), with tetanus (30, 25%) and HPV (22, 18.3%) the second and third most common. However, only 40% knew where adult vaccines are available, showing a major gap in vaccine-related awareness. 104 (69.3%) believed that vaccination strengthens immunity, 30 (20%) responded “don’t know,” and 16 (10.7%) held incorrect beliefs that vaccines weaken the body’s natural immunity.

Table 2: Vaccination status, knowledge, perceptions, and barriers (n = 150)

 

Effect of Counseling

Post the structured counseling session, there was a drastic improvement in the understanding of adult vaccination, with 128 (85.4%) reporting better awareness. Furthermore, 90 (60%) reported that they were now willing to get vaccinated, and 112 (74.7%) were willing to recommend adult vaccination to others. The counseling intervention resulted in a dramatic shift in attitudes, particularly in those previously unaware or reluctant.

 

Table 3: Impact of counseling on attitudes and willingness (n = 150)

 

This study assessed knowledge, attitude and perception towards adult vaccination among OPD attendees and showed the significant impact of structured counseling in increasing the awareness and acceptance. There are still gaps in the public understanding as only 69.3% of the participants thought that vaccines improve immunity and 60% thought that vaccines for adults are unnecessary. Larson et al.14 have also described such deficits and found misconceptions and misinformation as major global drivers of hesitancy. The main barrier to adult immunization was found to be lack of awareness by 60% of the respondents in our study. This is in agreement with the findings of Verma et al. and Ozisik et. al. who found that lack of knowledge is the most common barrier to adult immunization in low- and middle-income countries.15,16

 

While 80% of respondents had received at least one adult vaccine, the overwhelming focus of this uptake on COVID-19 immunization (90%) underlines the positive impact of nationwide mass campaigns but also points to low uptake of routine adult vaccines. Sridhar et al. also note that although large-scale vaccination drives enhance coverage for certain diseases, they do little to enhance awareness of the overall adult immunization schedule. The lower uptake of tetanus (25%) or HPV (18.3%) vaccines in the present study is in line with previous studies suggesting that non-mandated adult vaccines are often under-prioritized.17

 

Mistrust (20.1%) and fear of injection (19.9%) also contributed to hesitancy in this study. Dube et al.  and Schmid et al. reported similar findings, emphasizing the significance of psychological and emotional factors, alongside knowledge gaps, in adult vaccine decision-making.18,19 Importantly, the large improvement in understanding after counseling (85.4%) and increased willingness to vaccinate (60%) are consistent with evidence from Brewer NT et al. who demonstrated that patient-centered vaccine communication significantly improves acceptance.20 The increase in participants who were willing to recommend vaccination to others (74.7%) further underscores the effectiveness of targeted educational interventions at the point of care.

 

Overall, the study supports that OPD-based counseling is a high-impact, low-cost approach to enhance adult vaccination efforts. Our findings are aligned with national and international evidence highlighting that improving awareness, reducing fears and improving communication by healthcare providers are important factors in improving vaccine uptake in adult populations.

Despite this, awareness and uptake of adult vaccination remain sub-optimal, with substantial misconceptions and information deficits driving hesitancy. The findings of this study suggest that structured counselling can significantly improve knowledge, attitudes, and willingness to vaccinate. Routine vaccine counseling embedded in OPD workflows could be a valuable approach to improving adult immunization coverage. Public health systems should focus on more extensive awareness campaigns and better patient-provider communication.

 

Limitations:

This study was conducted in a single tertiary care OPD, and convenience sampling was used, which may limit generalizability. Responses to post-counseling were recorded immediately, so we could not assess long-term retention of awareness or actual vaccination behavior. Further studies should be multicentric and longitudinal.

 

Recommendation:

Routine training in adult vaccine counseling should be provided to healthcare providers. Community-level awareness campaigns are needed to correct the prevalent misconceptions. Policy level efforts should focus on developing a national adult immunization guideline and improving the availability of recommended adult vaccines.

1.       Andre FE, Booy R, Bock HL, Clemens J, Datta SK, John TJ, et al. Vaccination greatly reduces disease, disability, death and inequity worldwide. Bull World Health Organ. 2008;86(2):140-6.

2.       Orenstein WA, Ahmed R. Simply put: Vaccination saves lives. Proc Natl Acad Sci U S A. 2017 Apr 18;114(16):4031-4033. 

3.       Sridhar S, Maleq N, Guillermet E, Colombini A, Gessner BD. A systematic literature review of missed opportunities for immunization in low- and middle-income countries. Vaccine. 2014 Dec 5;32(51):6870-6879. 

4.       Johnson DR, Nichol KL, Lipczynski K. Barriers to adult immunization. Am J Med. 2008 Jul;121(7 Suppl 2):S28-35.

5.       Verma R, Khanna P, Chawla S. Adult immunization in India: Importance and recommendations. Hum Vaccin Immunother. 2015;11(9):2180-2. 

6.       World Health Organization. Ten threats to global health in 2019. Geneva: WHO; 2019.

7.       Larson HJ, Jarrett C, Eckersberger E, Smith DMD, Paterson P. Understanding vaccine hesitancy around the world: A systematic review. Vaccine. 2014;32(19):2150-9.

8.       Dubé E, Laberge C, Guay M, Bramadat P, Roy R, Bettinger JA. Vaccine hesitancy: An overview. Hum Vaccin Immunother. 2013;9(8):1763-73.

9.       Lahariya C. A brief history of vaccines & vaccination in India. Indian J Med Res. 2014 Apr;139(4):491-511.

10.    Chin KY, Ekeuku SO, Hamzah MR. The Role of Healthcare Providers in Promoting Human Papillomavirus Vaccines among Men Who Have Sex with Men: A Scoping Review. Vaccines (Basel). 2022 Jun 10;10(6):930.

11.    Schmid P, Rauber D, Betsch C, Lidolt G, Denker ML. Barriers of Influenza Vaccination Intention and Behavior - A Systematic Review of Influenza Vaccine Hesitancy, 2005 - 2016. PLoS One. 2017 Jan 26;12(1):e0170550.

12.    Brewer NT, Chapman GB, Rothman AJ, Leask J, Kempe A. Increasing Vaccination: Putting Psychological Science Into Action. Psychol Sci Public Interest. 2017 Dec;18(3):149-207.

13.    MacDonald NE. Vaccine hesitancy: Definition, scope, and determinants. Vaccine. 2015;33(34):4161-4.

14.    Larson HJ, Jarrett C, Eckersberger E, Smith DMD, Paterson P. Understanding vaccine hesitancy around the world: A systematic review. Vaccine. 2014;32(19):2150-9.

15.    Verma R, Khanna P, Chawla S. Adult immunization in India: Importance and recommendations. Hum Vaccin Immunother. 2015;11(9):2180-2.

16.    Ozisik L, Calik Basaran N, Oz SG, Sain Guven G, Durusu Tanriover M. Perceptions and  Attitudes of Patients About Adult Vaccination and Their Vaccination Status: Still a Long Way to Go? Med Sci Monit. 2017 Jun 29;23:3178-3184.

17.    Sridhar S, Belhekar MN, Toraskar K, Thatte UM. Knowledge, attitudes and practices about adult vaccination among patients attending a tertiary care hospital in India. J Postgrad Med. 2021;67(3):137-143.

18.    Dubé E, Vivion M, MacDonald NE. Vaccine hesitancy, vaccine refusal and the anti-vaccine movement: influence, impact and implications. Expert Rev Vaccines. 2015 Jan;14(1):99-117.

19.    Schmid P, Rauber D, Betsch C, Lidolt G, Denker ML. Barriers of Influenza Vaccination Intention and Behavior - A Systematic Review of Influenza Vaccine Hesitancy, 2005 - 2016. PLoS One. 2017 Jan 26;12(1):e0170550.

20.    Brewer NT, Chapman GB, Rothman AJ, Leask J, Kempe A. Increasing Vaccination: Putting Psychological Science Into Action. Psychol Sci Public Interest. 2017 Dec;18(3):149-207.