Knowledge, attitudes and perceptions of health professionals in relation to A/H1N1 influenza and its vaccine.

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by  Lopez-Picado, Amanda

(cid:1)ORIGINAL RESEARCH ARTICLE
Knowledge, attitudes and perceptions
of health professionals in relation to
A/H1N1 influenza and its vaccine
Amanda Lo´pez-Picado1, Antxon Apin˜aniz2, Amaia Latorre
Ramos1, Erika Miranda-Serrano1, Raquel Cobos1,
Naiara Parraza-Dı´ez1, Patricia Amezua1, Mo´nica Martinez-
Cengotitabengoa3,4 and Felipe Aizpuru1,5,6*
1Araba ResearchUnit, ArabaUniversity Hospital, Vitoria-Gasteiz, Spain;2ArabaPrimary CareUnit,
Vitoria-Gasteiz, Spain; 3CIBERSAM, Centrode Investigacio´n Biome´dica enRed deSalud Mental, Madrid,
Spain;4Department ofPsychiatry,ArabaUniversitary Hospital, Vitoria-Gasteiz, Spain;5CIBER de
Epidemiologı´a ySaludPu´blica(CIBERESP), Madrid, Spain;6Facultyof Medicine, University ofthe Basque
Country,Vitoria-Gasteiz, Spain
Objective: Todeterminetheintentionofhealthprofessionals,doctorsandnurses,concerningwhetherornot
to be vaccinated against A/H1N1 influenza virus, and their perception of the severity of this pandemic
comparedwithseasonalflu.
MaterialandMethods: Across-sectionalstudywascarriedoutbasedonanquestionnairee-mailedtohealth
professionals in public healthcare centres in Vitoria between 6 and 16 November 2009; the percentage of
respondentswhowantedtobevaccinatedandwhoperceivedthepandemicflutocarryahighriskofdeath
werecalculated.
Results: Atotalof115peoplecompletedthequestionnaireofwhom61.7%(n(cid:1)71)weredoctorsand38.3%
(n(cid:1)44)werenurses.Ofthese,33.3%(n(cid:1)23)ofdoctorsand13.6%(n(cid:1)6)ofnursesintendedtobevaccinated
(p(cid:1)0.019).Evenamongthosewhoconsideredthemselvestobeatahighrisk,70.6%(n(cid:1)48)ofdoctorsand
31.7% (n(cid:1)13)of nurses participating in thestudy (p(cid:1)0.001) plannedtohavethevaccination.
Conclusions: Most health professionals, and in particular nurses, hadno intention to bevaccinated against
A/H1N1influenzavirus atthebeginning of thevaccination campaign.
Keywords: A/H1N1influenzavirus;vaccination;healthprofessionals;doctors;nurses
Received:4 September 2011; Revised:25 October 2011; Accepted:16 November 2011;Published:11January2012
Many international organisations have high- keenonbeingvaccinated:ithasbeenestimatedthatoverall
lighted the importance of vaccination against only between 40 and 50% of health professionals are
seasonalfluforhealthprofessionals(1(cid:2)4).The vaccinatedagainsttheseasonalfluvirus(6,7),andthese
recommendation is based onvarious factors such as the ratesareevenloweramongnurses(8(cid:2)10).
increased riskof complications associatedwith infection Many reasons have been put forward for not being
in patients in at-risk groups, the tendency to go to work vaccinated: fearof adverse reactions, underestimation of
despiteflusymptoms,andthe highrates oftransmission severity of the flu epidemic, lack of time and doubts
among colleagues. All these elements translate to an concerning safety, among others (11(cid:2)14). Despite this, it
increase in costs and deaths. seems that among health professionals who are better
Infact,ithasbeendemonstratedthatthevaccinationof informed and know the risk factors more tend to accept
health professionals is associated with a decrease in the the vaccination, so a deeper understanding of the
number of deaths of patients attended at home and vaccinemayhelptoincreasewillingnesstobevaccinated
of patients with high-risk medical conditions (5). (13(cid:2)17).
Despiteseveralstudieshavingdemonstratedthemultiple In 2009, the seasonal flu vaccination campaign was
advantages of vaccination, health professionals are not preceded by that of the A/H1N1 flu virus. Since the
EmergingHealthThreatsJournal2012.#2012AmandaLo´pez-Picadoetal.ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommons 1
Attribution-Noncommercial3.0UnportedLicense(http://creativecommons.org/licenses/by-nc/3.0/),permittingallnon-commercialuse,distribution,andreproductionin
anymedium,providedtheoriginalworkisproperlycited. Citation:EmergingHealthThreatsJournal2012,5:7266-DOI:10.3402/ehtj.v5i0.7266
(pagenumbernotforcitationpurpose)
AmandaLo´pez-Picadoetal.
outset, the A/H1N1 virus has raised great concern in effectiveness of the A/H1N1 flu vaccine, and research
society,giventhatitishighlyinfectious,moresothanthe undertaken to produce the vaccine. The response cate-
seasonal flu virus (18) and that the prevalence is higher gories were ‘yes’, ‘no’, and ‘don’t know/no opinion’, the
among children (19). latter leading to classification as undecided.
Given these factors, vaccination against this type of Lastly, data related to understanding of the routes
virus is particularly important. In this context, it is of transmission, the perception of risk associated with
essential to remember that any preventive measures, the virus, and the comparison of A/H1N1 flu with
including vaccines, are ineffective without the collabora- seasonal virus were collected in the final section of the
tion of the population and health professionals (20(cid:2)23). questionnaire.
Adherencetorecommendationsofthissortisdetermined
by perception of the level of danger (5), and of
the effectiveness of the measures (21, 24). In short, the Analysisoftheresults
perception of danger and the understanding of health Descriptive statistics were calculated for the main char-
professionals of the A/H1N1 flu virus may directly acteristicsofthesample.Themainoutcomewasassessed
affect acceptance of and adherence to these measures by calculating the percentage of doctors and nurseswho
and influence the perception of the general population had the intention to be vaccinated against the A/H1N1
(25, 26).
flu virus, comparedwith those who did not intend to be
For these reasons, the aim of this study was to
vaccinated, in the cases of the vaccine being free and of
determine the intention to be vaccinated against A/ having to pay for it (t10). Any association between
H1N1 flu virus among health professionals in relation
intention to vaccinate and sociodemographic variables
to levels of understanding, attitudes and perception of
includingage,sex,levelofeducation,civilstatus,employ-
risk just before the vaccination campaign at the peakof
mentstatusandunderstandingoftheroutesoftransmis-
the epidemic.
sion was explored using the Chi square test and p for
linear trend for ordinal variables. In addition, the
Materials and methods
intention to be vaccinated was calculated as a function
An observational cross-sectional study was carried out of prior behaviour, namely, whether or not they had
amonghealthprofessionalsoftheBasqueHealthSystem
previouslybeenvaccinatedagainsttheseasonalfluvirus.
in Vitoria-Gasteiz.
Theanalysisofthemainvariables(intentiontovaccinate
Data collection started on 6 November, coinciding
against the seasonal and A/H1N1 flu viruses, having
with the peak of the A/H1N1 virus epidemic in the
previously been vaccinated against seasonal flu, percep-
Basque Country, and ended on 16 November, when the
tionofrisk,anddoubtsconcerningtheeffectivenessand
vaccination campaign was launched in our autonomous
safetyof the vaccine) were adjusted for age and sex. We
region,despitethefactthattheexpectedsamplesizehad
considered a level of significance of a(cid:1)0.05. Statistical
not been reached.
analysiswascarriedout usingthe Statistical Packagefor
The questionnaire was sent by email to doctors (n(cid:1)
the Social Science (SPSS, version 16) for Windows.
900) and nurses (n(cid:1)1,326) of the acute care public
hospitals of Vitoria-Gasteiz (Txagorritxu and Santiago)
and primary care health centres in Araba. They were
Ethicalapproval
given the option of answering electronically or by post,
The study was approved by the Clinical Research Ethics
sending the questionnaire to the Research Unit, by
Committees of Txagorritxu and Santiago Hospitals.
internal mail within the Basque Health Service/Osaki-
detza.
The data collected in the survey were entered into a
dedicated computer database created using Microsoft Results
Access software.
Generalcharacteristics
Studyvariables Of the 2,226 emails sent (900 to doctors and 1,326 to
AquestionnairebasedonthatusedbyLauetal.(20)was nurses), 115 questionnaires were returned completed, of
producedconsistingof28questionsthatgatherinforma- which 71 (61.7%) and 44 (38.3%) were received from
tion concerning views on vaccination against A/H1N1 doctors and nurses, respectively. The sociodemographic
virus and the perception of risk (Appendix 1). characteristics of the two groups are shown in Table 1.
Questions were asked to assess the attitude of profes- Overall,64.3%(n(cid:1)74)ofthesamplehadbeenvaccinated
sionals towards vaccination against A/H1N1 flu virus against the seasonal flu at some stage. This percentage
both if it were free of charge and if it had a cost of t10. was higher (p(cid:1)0.018) among doctors (71.8%, n(cid:1)51)
There were also questions concerning the safety and than nurses (52.3%, n(cid:1)23).
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A/H1N1influenzaanditsvaccine
Table1. Sociodemographiccharacteristics UnderstandingoftheA/H1N1pandemicandroutes
oftransmission
n(cid:1)115 Doctors(n(cid:1)71) Nurses(n(cid:1)44) Withregardstotheroutesoftransmission,74.6%(n(cid:1)53)
of doctors and 75% (n(cid:1)33) of nurses were properly
Sex
informed. Among these, 65.1% had obtained the infor-
Male 29(40.8%) 6(13.6%)
mation through colleagues, while 20.9% cited the media,
Female 42(59.2%) 38(86.4%)
and the remaining respondents had acquired the knowl-
Age edge from other sources.
Media9SD 42.599.9 43.3910.1
530years 10(15.4%) 6(14.3%) Perceptionofriskofinfectionandseverityoftheflu
30(cid:2)65years 55(84.6%) 36(85.7%) Doctors had a higher perception of risk of infection by
A/H1N1 influenza virus than nurses. They considered
Maritalstatus
that they, and their own families and the general
Single 17(25.4%) 13(29.5%)
population, were at high risk of becoming infected
Married/couple 50(74.6%) 31(70.5%)
(pB0.05). Data regarding this section of the question-
naire are shown in Table 2.
AttitudetowardsvaccinationagainstA/H1N1 With regards to mortality, 68.1% (n(cid:1)47) of doctors
influenzavirus and79.1%(n(cid:1)34)ofnursesthoughtthat,in2009,oneto
Atotalof33.3%(n(cid:1)23)ofdoctorshadtheintentionto 10peopleweregoingtodiedueto thistypeofflu inthe
be vaccinated against the A/H1N1 flu virus, compared local area (Vitoria-Gasteiz). On the other hand, 14.5%
with 13.6% (n(cid:1)6) of nurses (p(cid:1)0.023). These percen- (n(cid:1)10) and 16.3% (n(cid:1)7) of doctors and nurses,
tages were even lower if the vaccine was not free (t10), respectively, thought that nobody was going to die,
both among the doctors (27.5%; n(cid:1)19) and the nurses whereas 14.5% (n(cid:1)10) of doctors and 4.7% (n(cid:1)2) of
nurses thought that between 10 and 50 individuals (p(cid:1)
(6.8%; n(cid:1)3).
0.247) would die.
Amongthosewhoconsideredthemselvestobeathigh
Atotalof41.4%(n(cid:1)29)ofdoctorsand45.5%(n(cid:1)20)
riskofcontractingA/H1N1flu,70.6%(n(cid:1)48)and31.7%
ofnursesbelievedthattheharmcausedbytheA/H1N1flu
(n(cid:1)13)ofdoctorsandnurses,respectively,indicatedthat
virus was similar to that of the seasonal influenzavirus
they would be vaccinated. There was a statistically
(p(cid:1)0.015), while 43.7% (n(cid:1)31) of doctors and 59.1%
significant difference between the two groups, doctors
(n(cid:1)26)ofnursesthoughtthatA/H1N1fluwouldhavea
and nurses (p(cid:1)0.002).
muchlowerrateofmortalitythanseasonalflu(p(cid:1)0.17).
Among the nurses, no significant difference was
detected in intention to be vaccinated between those
Discussion
whohad(n(cid:1)4;11.4%)andhadnothadtheseasonalflu
Theprimaryobjectiveofthisstudywastodeterminethe
jab previously (n(cid:1)5; 11.4%, p(cid:1)0.166). Likewise, inten-
intentionof healthprofessionalstobevaccinated aswell
tiontobevaccinatedwasnotsignificantlyhigheramong
astheirperceptionoftheseverityoftheinfectioncaused
doctorswhohadbeenpreviouslybeenvaccinatedatleast
by the A/H1N1 influenzavirus, as investigated by other
onceagainsttheseasonalfluvirus(n(cid:1)51),41.2%(n(cid:1)21,
researchers (13, 15, 16, 27(cid:2)29), in relation to this and
p(cid:1)0.126) expressing an intention to receive the H1/N1
other pandemics associatedwith various subtypes of the
vaccine.
influenzavirus.Atotalof2,226questionnairesweresent
of which just 115 were returned completed (5.2%). This
overall percentage is lower than that achieved in other
AcceptanceoftheA/H1N1influenzavirusvaccine
studies(12,15,25,26)andinotherprojectscarriedoutin
andperceptionofitseffectiveness
A total of 69.8% (n(cid:1)30) of the nurseswho participated
Table2. Doyouthinkthereisahighriskofsufferingfrom
objectedtobeingvaccinated,whilethisfigurewas48.5% swineflu
(n(cid:1)33) among the doctors (p(cid:1)0.04). Significant differ-
enceswerealsofoundbetweenthegroupswithregardsto Yes(%) No(%) p
the perception of effectiveness of the vaccine. Among
You? Doctors 54(78.3) 15(21.7) 0.013
respondents, 63.3% (n(cid:1)38) of the doctors considered
Nurses 26(59.1) 18(40.9)
that the vaccine was effective, compared with 35.1%
Ownfamily? Doctors 58(84.1) 11(15.9) 0.01
(n(cid:1)13)ofthenurses(p(cid:1)0.044).Evenamonghealthcare
Nurses 28(63.6) 16(36.4)
workers who trusted in the effectiveness of the vaccine
Generalpopulation? Doctors 56(81.2) 13(18.8) 0.031
(n(cid:1)51), more than half did not intend to be vaccinated
Nurses 25(56.8) 19(43.2)
(n(cid:1)26; 51%).
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AmandaLo´pez-Picadoetal.
thesameareabythisresearchteam(23),thoughtherate thefindingsofastudycarriedoutbyLauetal.(20),ina
of response from nursing staff was similar to that different cultural setting, Hong Kong, in which 73% of
obtained by other researchers (2, 3). The overall low the respondents from the general population had no
rateofresponsemaybeduetotheshortwindowoftime objections to being vaccinated.
during which questionnaires were accepted, given the In our study, the response was stronger among the
importance of it being completed before the vaccination nurses, who in most cases objected to being vaccinated
campaign began. and believed that there had not been sufficient research
The overall percentage of thosevaccinated against the on the vaccine. This, together with the fact that manyof
seasonal flu at least once before was higher than that themquestionedtheeffectivenessofthevaccine,leadsus
observed in other studies (30), though similar values to toconcludethat,inoursample,themainreasonsfornot
thosereportedelsewherewerefoundfornurses(31),who, beingvaccinatedaretheperceptionoflackofsafetyand
in general, are less keen to be vaccinated (5, 6). The ofeffectivenessofthevaccine,whichhavealsobeencited
overallhigherratemaybeduetothefactthatthevaccine byother researchers (11, 13).
is offered for free in the centres themselves, which According to our results, however, these are not the
facilitates access andhencetends toincreasethenumber only factors that can affect the levels of vaccination:
of staff vaccinated (13). Nevertheless, various authors specifically, a lower rate of intention to vaccinate was
have suggested that easy access to vaccines is not detected among the health personnel who perceived the
sufficient and that it should be combined with other pandemicasalow-risksituation,inagreementwithwhat
measuressuchaseducationalprogrammesandeconomic hasbeenobservedinotherstudies(11,23,35).Whenthe
incentives to achieve high vaccination rates (31, 32). In dataarebrokendown,wenotethatagainitisthenurses
our study, we did not focus on assessing the effect of whoreportthelowestratesofintentiontobevaccinated.
incentives but we did observe that having to pay for This is supported by the fact that quite a few of the
vaccinesconsiderablydecreasedtheintentiontovaccinate respondentsconsideredthatwhiletheyandtheirfamilies
in both groups, particularly in the case of nurses. Some were at risk of being infected, they believed that the
authors have recommended the introduction of health mortality associatedwith the A/H1N1 viruswas low.
education campaigns especially focused on this profes- Despite numerous studies having demonstrated a
sionalgroup(33,34),butseveralstudiessuggestthatsuch greater risk of contracting A/H1N1 flu in young people
programmes do not achieve higher rates of vaccine (39)andagreaterriskofseveresymptomsininfantsand
acceptance (35(cid:2)37). older individuals (40, 41), among the healthcareworkers
On the other hand, the intention to vaccinate against surveyed such findings did not seem to increase percep-
A/H1N1 influenza virus among respondents is similar tionofriskortranslatetoagreaterintentiontovaccinate
(25.7%) to other studies in Spain (38), and is within the againstthepandemic.Indeed,weobservednosignificant
wide range reported to date from studies conducted variationsintheopinionoftheprofessionalssurveyedby
elsewhere (9, 20, 26, 39, 40) (11(cid:2)67%). A greater will- ageorbysex,butrathertheirintentionswereaffectedby
ingness tovaccinate was also detected among thosewho personal perception of the risks (11, 23, 35) and their
had been vaccinated before against seasonal flu, in confidence in the effectiveness of the vaccine (11, 17).
agreementwithwhatisfoundintheliterature(13,26,41). In short, it is essential to determine the barriers to
Incontrasttofindingsofotherresearchers(16),wedid being vaccinated among health professionals, since this
notfindahighertendencytobevaccinatedamongthose low willingness not only has an negative impact on the
whowereproperlyinformed.Thismightbeattributableto level of absenteeism, and hence on the healthcare
thecriteriafollowedfordeterminingwhetherrespondents provided(16,29,31),butalsoontherateoftransmission
were ‘properly informed’ and the personal perception of of the disease between health professionals and patients,
individualhealthprofessionals,amongotherfactors. (13, 32) and this, without any doubt, is the most
The main reported arguments against vaccination are important consequence.
thefearoftheoccurrenceofadversereactions(13)andthe Moreover, the effect of the beliefs of health profes-
lack of effectiveness (11, 20). In relation to this, several sionals, in particular those of doctors (38), on patients
studies have found differences between the two groups regardingcertainissuesshouldnotbeunderestimated,as
surveyed,namelythatfornursesthemainobstacletobeing patientswhoareadvisedbytheirdoctortobevaccinated
vaccinated tends to be a fear of adverse reactions (13), tendtofollowthisadvice.Hence,anymeasuretoimprove
whereasfordoctorsitisthelackofeffectiveness(11,17). thelevel of understandingconcerning thisand anyother
Inourstudy,mostrespondentshadobjectionstobeing pandemic among health professionals translates to a
vaccinated and did not trust in the effectiveness of the greater awareness among the general population and,
vaccine. This is in agreement with the results obtained correspondingly, a higher rate of vaccination (38).
with regards to this pandemic in the general population Thelimitationsofthestudyincludetheshortwindowof
inourgeographicalarea(23,38),butverydifferentfrom timeavailableforsendingandreceivingthequestionnaires
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A/H1N1influenzaanditsvaccine
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26. IsaacsonN,Roemheld-HammB,CrossonJC,Dicicco-BloomB, 2001;23:346(cid:2)8.
Winston CA. Organizational culture influences health care 37. Lam PP, Chambers LW, Pierrynowski MacDougall DM,
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33. To KW, Lee S, Chan TO, Lee SS. Exploring determinants of C/JoseAtxoteguis/n
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34. Ofstead CL, Tucker SJ, Beebe TJ, Poland GA. Influenza Tel:(cid:4)34945007413
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knowledge,anddecision-makingataninstitutionwithamulti- Email:[email protected]
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Citation:EmergingHealthThreatsJournal2012,5:7266-DOI:10.3402/ehtj.v5i0.7266
(pagenumbernotforcitationpurpose)
A/H1N1influenzaanditsvaccine
Dear Colleagues, 10. Do you know which are the at-risk groups with
respect to A(H1N1) flu?
The Research Unit of Txagorritxu Hospital and 1. Yes
Research Commission for the Health Region of Araba 2. No
arestudyingviewsconcerningA/H1N1influenza.Wewill
11.Ifyouwereinoneoftheat-riskgroups,wouldyou
be most grateful if you take part.
be vaccinated?
Theinformationcollectedwillremainanonymous.You
1. Yes
can return the completed questionnaire by e-mail (to
2. No
[email protected])
orthroughtheinternalmail,addressingittothesecretary 12.DoyouthinkthatA(H1N1)fluisspreadbycoughs
of the Txagorritxu Hospital’s Research Unit. and sneezes?
1. Yes
QUESTIONNAIRE 2. No
13. Do you think that A(H1N1) flu can be spread by
a) General questions physical contact (e.g., shaking hands)?
1. Sex 1. Yes
1. Woman 2. No
2. Man
14. Do you think that A(H1N1) flu can be spread by
2. Yearof birth contactwithcontaminatedsurfaces(e.g.,bytouch-
ing a door handle)?
3. Profession
1. Yes
1. Doctor
2. No
2. Nurse
3. Other
c) Your perception of the severityof the A(H1N1) flu
4. Civil status
1. Single
15. What percentage of the general population doyou
2. Married/With partner
think will get A(H1N1) flu?
5. What is your employment status? 1. B1%
1. Permanent contract 2. 1(cid:2)5%
2. Temporary contract 3. (cid:4)5%
3. Casual contract
16. Doyou think that A(H1N1) flu could have severe
6. Have you ever received a seasonal flu jab? andirreversibleeffectsonthehealthofthegeneral
1. Yes population?
2. No 1. Yes
2. No
7.Whathasbeenyourprincipalsourceofinformation
on A(H1N1) flu? 17. How many deaths do you think the A(H1N1) flu
1. Healthcare colleagues will cause in our region (Vitoria-Gasteiz) in 2009?
2. The media 1. None
3. Other 2. 1(cid:2)10
3. 11(cid:2)50
4. (cid:4)50
b) Hypothetical situations
18.DoyouthinkthatsomepeoplehavehadA(H1N1)
8. If it were free, would you have the A(H1N1) flu flu and have not realised?
jab? 1. Yes
1. Yes 2. No
2. No
19.Doyouthinkthatthisillnesswillaffectmostofthe
9. Andwould have the jab if it cost t10? population in our region (Vitoria-Gasteiz)?
1. Yes 1. Yes
2. No 2. No
7
Citation:EmergingHealthThreatsJournal2012,5:7266-DOI:10.3402/ehtj.v5i0.7266
(pagenumbernotforcitationpurpose)
AmandaLo´pez-Picadoetal.
d) Perception of risk 1. Many fewer
2. Slightly fewer
20. Do you think that you are at high risk of getting 3. The same
A(H1N1) flu? 4. Slightly more
1. Yes 5. Many more
2. No
25.HowmuchharmdoyouthinktheA(H1N1)fluwill
21.Doyouthinkthatthereisahighriskthatsomeone cause compared to seasonal flu? (What level of
inyour family will get A(H1N1) flu? damagewillbecausedtothebodybyA(H1N1)flu
1. Yes in relation to seasonal flu?)
2. No 1. Much less
2. Slightly less
22.Doyouthinkthatthereisahighriskthatmembers
3. The same
of the general population will get A(H1N1) flu?
4. Slightly more
1. Yes
5. Much more
2. No
26. Do you have any objections to receiving the
A(H1N1) flu vaccine?
e) Comparison of A(H1N1) flu with seasonal flu
1. Yes
2. No
23. How many deaths do you think A(H1N1) flu will
cause compared to normal (seasonal) flu? That is, 27. Do you think that the vaccine is effective at
we are asking you to rate how the mortality preventing A(H1N1) flu?
1. Yes
associated with A(H1N1) flu compares to that of
2. No
seasonal flu.
1. Many fewer 28.Doyouthinkthattherehasbeensufficientresearch
2. Slightly fewer into thevaccine?(Inyouropinion, havetherebeen
3. The same enough studies/clinical trials/research to demon-
4. Slightly more strate the effectiveness of the vaccine?)
5. Many more 1. Yes
2. No
24. How many people do you think will be infected
compared to normal (seasonal) flu? (That is, how
do you think the rate of infection will compare
THANK-YOU VERY MUCH FORYOUR HELP
between A(H1N1) flu and seasonal flu?)
8
Citation:EmergingHealthThreatsJournal2012,5:7266-DOI:10.3402/ehtj.v5i0.7266
(pagenumbernotforcitationpurpose)