Knowledge, attitudes and practices (KAP) towards vaccinations in the school settings: an explorative survey


Vaccination recommendation
Vaccine preventable disease
School environment
Vaccine hesitancy


Background. Past researches have shown that schoolteachers’ (STs) interventions maximize the consent for vaccination programs. European data regarding knowledge, attitudes and practices of STs towards vaccination are otherwise lacking.

Objectives. The aim of this study was to evaluate knowledge and attitudes of STs regarding vaccinations in a sample from North Italy.

Material and methods. In this cross sectional study, 154 STs from Lombardy region (Northern Italy) responded to a specific questionnaire assessing their attitude towards vaccination and vaccine related knowledge.

Results. In general, 88.3% of subjects were somehow favourable to vaccinations. The main reason for declining vaccination was the risk of side effects whereas the main reason to be vaccinated was to avoid to be infected by VPDs (67.6%). Main information sources were health professionals (75.3%), and new media (13.1%), and the latter were STs more frequently associated with a negative attitude towards vaccinations (p < 0.001). Eventually, regression analysis identified risk perception as positively associated with propensity towards vaccinations, both for Students- and STs-recommended vaccinations (B = 0.372, 95%CI 0.247 to 0.496 and B = 0.005, 95%CI 0.004 to 0.006, respectively).

Conclusions. Our results are consistent with previous reports suggesting a significant knowledge gap in STs, with the risk perception of infectious diseases as the main predictor for vaccine propensity. Moreover, the better knowledge of official vaccination recommendations and policies among STs identifying Health Professionals as information source enlightens the role of the School Physicians and Occupational Physicians, whose intervention may ultimately increase the vaccination acceptance and vaccination rates.


Bloom BR, Marcuse E., Mnookin S. Addressing Vaccine Hesitancy. Science, 2014;344:339–339 doi:10.1126/science.1254834

Centers for Disease Control and Prevention. Achievements in Public Health, 1900-1999. MMWR 1999;48:243–248.

Bonanni P, Bergamini M. Factors influencing vaccine uptake in Italy. Vaccine, 2002;20:S8–S12.

Bonanni P, Bechini A, Boccalini S, Peruzzi M, Tiscione E, Boncompagni G, Mannelli F, Salmaso S, Filia A, Ciofi degli Atti M.. Progress in Italy in control and elimination of measles and congenital rubella. Vaccine 2007;25:3105–3110. doi:10.1016/j.vaccine.2007.01.019

Weigel M, Bruns R, Weitmann K, Hoffmann W. Immunization Rates at the School Entry in 2012 - Nationwide German Data With Regional and Local Breakdown. Dtsch Arztebl Int 2014;111:788–794. doi:10.3238/arztebl.2014.0788

Omer SB, Salmon DA, Orenstein WA, deHart MP, Halsey N. Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases. N Engl J Med 2009;360:1981–1988. doi:10.1056/NEJMsa0806477

Macintosh J, Luthy KE, Beckstrand RL, Eden LM, Orton J. Vaccination perceptions of school employees in a rural school district. Vaccine 2014;32:4766–4771. doi:10.1016/j.vaccine.2014.06.029

Veronesi L, Virdis R, Bizzoco S, Colucci ME, Affanni P, Paganuzzi F, Riccò M, Capobianco E, Tanzi ML. Vaccination status and prevalence of enteric viruses in internationally adopted children. Acta Biomed 2011;82:208–213

Zingg A, Siegrist M. Measuring people's knowledge about vaccination: Developing a one-dimensional scale. Vaccine 2012;30:3771–3777. doi:10.1016/j.vaccine.2012.03.014

Giannattasio A, Mariano M, Romano R, Chiatto F, Liguoro I, Borgia G, Guarino A, Lo Vecchio A. Sustained low influenza vaccination in health care workers after H1N1 pandemic: a cross sectional study in an Italian health care setting for at-risk patients. BMC Infect Dis 2015;15;329. doi:10.1186/s12879-015-1090-x

Bonanni P, Ferro A, Guerra R, Iannazzo S, Odone A, Pompa MG, Rizzuto E, Signorelli C. Vaccine coverage in Italy and assessment of the 2012- 2014 National Immunization Prevention Plan. Epidemiol Prev 2015;39:145–158.

Bonaccorsi G, Santomauro F, Porchia B, Niccolai G, Pellegrino E, Bonanni P, Lorini C. Beliefs and Opinions of Health Care Workers and Students Regarding Influenza and Influenza Vaccination in Tuscany, Central Italy. Vaccines, 2015;3:137–147. doi:10.3390/vaccines3010137

Alicino C, Iudici R, Barberis I, Paganino C, Cacciani R, Zacconi M, Battistini A, Bellina D, Di Bella AM, Talamini A, Sticchi L, Morando A, Ansaldi F, Durando P. Influenza vaccination among healthcare workers in Italy. Hum Vaccin Immunother, 2015;11:95–100. doi:10.4161/hv.34362

Biasio LR, Corsello G, Costantino C, Fara GM, Giammanco G, Signorelli C, Vecchio D, Vitale F. Communication about vaccination: A shared responsibility. Hum Vaccin Immunother 2016;12:2984-2987. doi:10.1080/21645515.2016.1198456

Signorelli C, Odone A, Bonanni P, Russo F. New Italian immunisation plan is built on scientific evidence: Carlo Signorelli and colleagues reply to news article by Michael Day. BMJ, 2015;h6775–1. doi:10.1136/bmj.h6775

Betsch C, Wicker S. Personal attitudes and misconceptions, not official recommendations guide occupational physicians’ vaccination decisions. Vaccine, 2014;32:4478–4484. doi:10.1016/j.vaccine.2014.06.046

Hull HF, Ambrose CS. Current Experience with School-located influenza vaccination programs in the United States. Hum Vaccin 2011;7:153–160. doi.10.4161/hv.7.2.13668

Fefferman NH, Naumova EN. Dangers of vaccine refusal near the herd immunity threshold: a modelling study. Lancet Infect Dis 2015;15:922–926. doi:10.1016/S1473-3099(15)00053-5

Dubé E, Gagnon D, MacDonald NE, SAGE Working Group on Vaccine Hesitancy. Strategies intended to address vaccine hesitancy: Review of published reviews. Vaccine 2015;33:4191–4203. doi:10.1016/j.vaccine.2015.04.041

Mikolajczyk RT, Akmatov MK, Rastin S, Kretzschmar M. Social contacts of school children and the transmission of respiratory-spread pathogens. Epidemiol Infect 2008;136:813–822. doi:10.1017/S0950268807009181

Ha C, Rios LM, Pannaraj PS. Knowledge, Attitudes, and Practices of School Personnel Regarding Influenza, Vaccinations, and School Outbreaks. Journal of School Health, 2013;83:554–561. doi: 10.1111/josh.12065.

Luthy KE, Thompson KE, Beckstrand RL, Macintosh JLB, Eden LM. Perception of safety, importance, and effectiveness of vaccinations among urban school employees in Utah. J Am Assoc Nurse Pract 2015;27:313–320. doi:10.1002/2327-6924.12233

Luthy KE, Houle K, Beckstrand RL, Macintosh J, Lakin RG. Vaccination Perceptions and Barriers of School Employees: A Pilot Study. J Sch Nurs 2013;29:284–293. doi:10.1177/1059840513490029

Larson HJ, Jarrett C, Eckersberger E, Smith DMD, Paterson P. Understanding vaccine hesitancy around vaccines and vaccinations from a global perspectives: a systematic review of published literature, 2007-2012. Vaccine, 2014;32:2150–2159 doi:10.1016/j.vaccine.2014.01.081

Larson HJ, Cooper LZ, Eskola J, Katz S, Ratzan S. New Decade of Vaccines 5: Addressing the vaccine confidence gap. The Lancet, 2011;378:526–535. doi:10.1016/S0140-6736(11)60678-8

Dempsey AF, Schaffer S, Singer D, Butchart A, Davis M, Freed GL. Alternative Vaccination Schedule Preferences Among Parents of Young Children. Pediatrics, 2011;128:848–856. doi:10.1542/peds.2011-0400

Gust DA, Darling N, Kennedy A, Schwartz B. Parents With Doubts About Vaccines: Which Vaccines and Reasons Why. Pediatrics, 2008;122:718–725. doi:10.1542/peds.2007-0538

Ladner J, Besson MH, Rodrigues M, Audureau E, Saba J. Performance of 21 HPV vaccination programs implemented in low and middle-income countries, 2009-2013. BMC Public Health 2014;14:670. doi: 10.1186/1471-2458-14-670

Soofi SB, Haq IU, Siddiqui MB, Mirani M, Tahir R, Hussain I, Puri MK, Suhag ZH, Khowaja AR, Lasi AR, Clemens JD, Favorov M, Ochiai RL, Bhutta ZA.. School as potential vaccination venue for vaccines outside regular EPI schedule: results from a school census in Pakistan. BMC Res Notes, 2012;5:6. doi: 10.1186/1756-0500-5-6

De Perio MA, Wiegand DM, Brueck SE. Influenza Vaccination Coverage Among School Employees: Assessing Knowledge, Attitudes, and Behaviors. J Sch Health 2014;84:586–592 doi:10.1111/josh.12184

Gargano LM, Painter JE, Sales JM, Morfaw C, Jones LM, Murray D, Wingood GM, DiClemente RJ, Hughes JM. Seasonal and 2009 H1N1 influenza vaccine uptake, predictors of vaccination and self-reported barriers to vaccination among secondary school teachers and staff. Hum Vaccin 2011;7:89–95 doi:10.4161/hv.V.I.13460

Luthy KE, Thompson KE, Beckstrand RL, Macintosh JLB, Eden LM. Perception of safety, importance, and effectiveness of vaccinations among urban school employees in Utah. J Am Assoc Nurse Pract 2015;27:313–320. doi:10.1002/2327-6924.12233

De Perio MA, Wiegand DM, Evans SM. Low influenza vaccination rates among child care workers in the United States: assessing knowledge, attitudes, and behaviors. J Community Health 2012;37:272–281 doi:10.1007/s10900-011-9478-z

Yaqub O, Castle-Clarke S, Sevdalis N, Chataway J. Attitudes to vaccination: a critical review. Soc Sci Med 2014;112(C):1–11 doi:10.1016/j.socscimed.2014.04.018

Rose SB, Lanumata T, Lawton BA. Promoting uptake of the HPV Vaccine: the knowledge and views of school staff. J Sch Health 2011;81:680–687. doi:10.1111/j.1746-1561.2011.00644.x

Goldstein ST, Cassidy WM, Hodgson W, Mahoney FJ. Factors associated with student participation in a schoolbased hepatitis B immunization program. J Sch Health 2001;71:184–187

Tung CS, Middleman AB. An evaluation of school-level factors used in a successful school-based hepatitis B immunization initiative. J Adolesc Health 2005;37:61–68. doi:10.1016/j.jadohealth.2004.07.019

Jourdan D, Pommier J, Quidu F. Practices and representations of health education among primary school teachers. Scand J Public Health 2010;38:86–94 doi:10.1177/1403494809350518

Salmon DA, Moulton LH, Omer SB, Chace LM, Klassen A, Talebian P, Halsey NA. Knowledge, Attitudes, and Beliefs of School Nurses and Personnel and Associations With Nonmedical Immunization Exemptions. Pediatrics, 2004;113:e552–e559.

Signorelli C, Riccò M, Odone A. The Italian National Health Service expenditure on workplace prevention and safety (2006-2013): a national-level analysis. Ann Ig. 2016;28:313-8. http:/dx.doi:10.7416/ai.2016.2111.

Riccò M, Cattani S, Casagranda F, Gualerzi G, Signorelli C. Knowledge, attitudes, beliefs and practices of Occupational Physicians towards vaccinations of Health Care Workers: a cross sectional pilot study from North-Eastern Italy. Int J Occup Med Environ Health 2017;30:775-790 doi:10.13075/ijomeh.1896.00895

Riccò M, Cattani S, Veronesi L, Colucci ME. Knowledge, attitudes, beliefs and practices of construction workers towards tetanus vaccine in Northern Italy. Ind Health 2016;54:554-563 doi:10.2486/indhealth.2015-0249

Riccò M, Razio B, Panato C, Poletti L, Signorelli C. Knowledge, Attitudes and Practices of Agricultural Workers towards Tetanus Vaccine: a Field Report. Ann Ig 2017;29:239-255 doi:10.7416/ai.2017.2156

Betsch C, Korn L, Holtmann C. Don’t try to convert the antivaccinators, instead target the fence-sitters. Proc Natl Acad Sci U S A 2015;112:E6725-E6726. doi:10.1073/pnas.1516350112

Leask J. Target the fence-sitters. Nature 2011;473:443–445. doi: 10.1038/473443a.

Pulcini C, Massin S, Launay O, Verger P. Knowledge, attitudes, beliefs and practices of general practitioners towards measles and MMR vaccination in southeastern France in 2012. Clin Microbiol Infect 2014;20:38–43. doi:10.1111/1469-0691.12194

Carrillo-Santisteve P, Lopalco PL. Measles still spreads in Europe: who is responsible for the failure to vaccinate? Clin Microbiol Infect 2012;18:S50–S56. doi:10.1111/j.1469-0691.2012.03982.x

Maltezou HC, Gargalianos P, Nikolaidis P, Katerelos P, Tedoma N, Maltezos E, Lazanas M. Attitudes towards mandatory vaccination and vaccination coverage against vaccine-preventable diseases among health-care workers in tertiary-care hospitals. J Infect 2012;64:319–324. doi:10.1016/j.jinf.2011.12.004

Tafuri S, Gallone MS, Cappelli MG, Martinelli D, Prato R, Germinario C. Addressing the anti-vaccination movement and the role of HCWs. Vaccine, 2014;32:4860–4865. doi:10.1016/j.vaccine.2013.11.006

Barbadoro P, Marigliano A, Di Tondo E, De Paolis M, Martini E, Prospero E, D'Errico MM. Measles among Healthcare Workers in a Teaching Hospital in Central Italy. J Occup Health, 2012;54:336–339. doi: 10.1539/joh.12-0016-BR

Lopalco PL, Martin R. Measles still spreads in Europe: who is responsible for the failure to vaccinate? Euro Surveillance, 2010;15:pii=19557.

Barrière J, Vanjak D, Kriegel I, Otto J, Peyrade F, Estève M, Chamorey E.. Acceptance of the 2009 A(H1N1) influenza vaccine among hospital workers in two French cancer centers. Vaccine, 2010;28:7030–7034. doi:10.1016/j.vaccine.2010.08.021

Harrison N, Brand A, Forstner C, Tobudic S, Burgmann K, Burgmann H. Knowledge, risk perception and attitudes toward vaccination among Austrian health care workers: A cross-sectional study. Hum Vaccin Immunother 2016;12:2459-63. doi:10.1080/21645515.2016.1168959

Quach S, Pereira JA, Heidebrecht CL, Kwong JC, Guay M, Crowe L, Quan S, Bettinger JA; Public Health Agency of Canada/Canadian Institutes of Health Research Influenza Research Network (PCIRN) Vaccine Coverage Theme Group. Health care worker influenza immunization rates: The missing pieces of the puzzle. Am J Infect Control 2013;41:685–690. doi:10.1016/j.ajic.2012.09.022

Botelho-Nevers E, Gautret P, Biellik R, Brouqui P. Nosocomial transmission of measles: An updated review. Vaccine 2012;30:3996–4001. doi:10.1016/j.vaccine.2012.04.023

Hollmeyer HG, Hayden F, Poland G, Buchholz U. Influenza vaccination of health care workers in hospitals—A review of studies on attitudes and predictors. Vaccine 2009;27:3935–3944. doi:10.1016/j.vaccine.2009.03.056

Hofmann F, Ferracin C, Marsh G, Dumas R. Influenza Vaccination of Healthcare Workers: a Literature Review of Attitudes and Beliefs. Infection, 2006;34:142–147. doi:10.1007/s15010-006-5109-5

Spadea A, Unim B, Ursillo P, Saulle R, Giraldi G, Miccoli S, Barbato A, Corda B, D'Amici AM, Boccia A, La Torre G. [Effectiveness of a training course on influenza vaccination in changing medical students and healthcare workers attitudes towards vaccination]. Ig Sanita Pubbl 2013;69:387–402. Italian

Albano L, Matuozzo A, Marinelli P, Di Giuseppe G. Knowledge, attitudes and behaviour of hospital health-care workers regarding influenza A/H1N1: a cross sectional survey. BMC Infect Dis 2014;14:208. doi:10.1186/1471-2334-14-208

Cadeddu C, Di Thiene D, Ricciardi W, Boccia A, La Torre G. Knowledge about pandemic flu among Italian health care workers (HCWs) an Italian survey. J Prev Med Hyg, 2011;52:127–130.

Boccia A, Di Thiene D, De Giusti M, La Torre G. Seasonal and pandemic influenza: the role of communication and preventive strategies. J Prev Med Hyg, 2011;52:124–126.

Falato R, Ricciardi S, Franco G. [Influenza risk perception and vaccination attitude in medical and nursing students during the vaccination campaigns of 2007-2008 (seasonal influenza) and 2009/2010 (H1N1 influenza)]. Med Lav 2011;102:208–215. Italian

Bonfiglioli R, Vignoli M, Guglielmi D, Depolo M, Violante FS. Getting vaccinated or not getting vaccinated? Different reasons for getting vaccinated against seasonal or pandemic influenza. BMC Public Health, 2013;13:1221. doi:10.1186/1471-2458-13-1221

Caskey RN, Macario E, Johnson DC, Hamlish T, Alexander KA. A School-Located Vaccination Adolescent Pilot Initiative in Chicago: Lessons Learned. J Pediatric Infect Dis Soc. 2013;2:198–204. doi:10.1093/jpids/pit001

Grandahl M, Tydén T, Rosenblad A, Oscarsson M, Nevéus T, Stenhammar C. School nurses’ attitudes and experiences regarding the human papillomavirus vaccination programme in Sweden: a population-based survey. BMC Public Health 2014;14:540. doi:10.1186/1471-2458-14-540

Black S, Rappuoli R. A Crisis of Public Confidence in Vaccines. Sci Transl Med 2010;2:61mr1. doi: 10.1126/scitranslmed.3001738