title: The effect of physician's recommendation on seasonal influenza immunization in children with chronic diseases.
abstract: BACKGROUND
  Despite recommendations by Health Authorities, influenza immunization coverage remains low in children with chronic diseases. Different medical providers involved in the management of children with chronic conditions may affect the pattern of influenza vaccine recommendations and coverage. The likelihood of vaccination by type of provider in children with chronic conditions is poorly understood. Therefore, the objectives of this study were to analyze the pattern and the effect of recommendations for seasonal influenza immunization provided by different physician profiles to families of children with chronic diseases and to measure the frequency of immunization in the study population.
  
  
  METHODS
  We recruited children with chronic diseases aged 6 months-18 years who subsequently presented to specialty clinics for routine follow-up visits, during spring 2009, in three Italian Regions Families of children with chronic diseases were interviewed during routine visits at reference centers through a face-to-face interview. We analyzed the following immunization predictors: having received a recommendation toward influenza immunization by a health provider; child's sex and age; mothers and fathers' age; parental education and employment; underlying child's disease; number of contacts with health providers in the previous year. Influenza immunization coverage was calculated as the proportion of children who received at least one dose of seasonal influenza vaccine in the previous season. We calculated prevalence ratios and we used a generalized linear model with Poisson family, log link and robust error variance to assess the effect of socio-demographic variables, underlying diseases, and recommendations provided by physicians on influenza immunization.
  
  
  RESULTS
  We enrolled 275 families of children with chronic diseases. Overall influenza coverage was 57.5%, with a low of 25% in children with neurological diseases and a high of 91.2% in those with cystic fibrosis. While 10.6% of children who did not receive any recommendation toward influenza immunization were immunized, among those who received a recommendation 87.5-94.7% did, depending on the health professional providing the recommendation. Receiving a recommendation by any provider is a strong predictor of immunization (PR = 8.5 95% CI 4.6;15.6) Most children received an immunization recommendation by a specialty (25.8%) or a family pediatrician (23.3%) and were immunized by a family pediatrician (58.7%) or a community vaccinator (55.2%).
  
  
  CONCLUSIONS
  Receiving a specific recommendation by a physician is a strong determinant of being immunized against seasonal influenza in children with chronic diseases independently of other factors. Heterogeneity exists among children with different chronic diseases regarding influenza recommendation despite international guidelines. Increasing the frequency of appropriate recommendations toward influenza immunization by physicians is a single powerful intervention that may increase coverage in children with chronic conditions.
authors.affiliation: Bambino Gesù Children's Hospital, IRCCS, Piazza S, Onofrio 4, Rome 00165, Italy. pandolfi.elisabetta@gmail.com
authors.forename: Elisabetta
authors.initials: E
authors.lastname: Pandolfi
authors.forename: Maria Giulia
authors.initials: MG
authors.lastname: Marino
authors.forename: Emanuela
authors.initials: E
authors.lastname: Carloni
authors.forename: Mariateresa
authors.initials: M
authors.lastname: Romano
authors.forename: Francesco
authors.initials: F
authors.lastname: Gesualdo
authors.forename: Piero
authors.initials: P
authors.lastname: Borgia
authors.forename: Roberto
authors.initials: R
authors.lastname: Carloni
authors.forename: Alfredo
authors.initials: A
authors.lastname: Guarino
authors.forename: Antonietta
authors.initials: A
authors.lastname: Giannattasio
authors.forename: Alberto E
authors.initials: AE
authors.lastname: Tozzi
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D002908:Chronic Disease; D005260:Female; D006801:Humans; D007114:Immunization / Q000706:statistics & numerical data*; D007223:Infant; D007252:Influenza Vaccines / Q000008:administration & dosage*; D007251:Influenza, Human / Q000517:prevention & control*; D007558:Italy; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011368:Professional-Family Relations; D036301:Qualitative Research; D012621:Seasons
chemical_list: D007252:Influenza Vaccines