Assessment of U.S. health care personnel (HCP) attitudes towards COVID-19 vaccination in a large university health care system

Background

As a priority group, healthcare personnel (HCP) will be key to success of COVID-19 vaccination programs. The purpose of this study was to assess HCP willingness to get vaccinated and identify specific concerns that would undermine vaccination efforts.

Methods

We conducted a cross-sectional survey of HCP, including clinical and non-clinical staff, researchers, and trainees between November 23 ^rd ,2020 and December 5 ^th ,2020. The survey evaluated attitudes, beliefs and willingness to get vaccinated.

Results

A total of 5287 respondents had a mean age of 42.5 years (SD=13.56), and were 72.8% female (n=3842). Overall 57.5 % of individuals expressed intent to receive COVID-19 vaccine. 80.4% were physicians and scientists representing the largest group. 33.6% of registered nurses, 31.6% of allied health professionals, and 32% of master’s level clinicians were unsure they would take the vaccine (p<.001). Respondents who were older, males, White, or Asian were more likely to get vaccinated compared to other groups. Vaccine safety, potential adverse events, efficacy and speed of vaccine development dominated concerns listed by participants. Fewer (54.0%) providers of direct care vs. non-care providers (62.4%), and 52.0% of those who had provided care for COVID-19 patients (vs. 60.6% of those who had not) indicated they would take the vaccine if offered (p<.001).

Conclusions

We observed that self-reported willingness to receive vaccination against COVID-19 differs by hospital roles, with physicians and research scientists showing the highest acceptance. These findings highlight important heterogeneity in personal attitudes among HCPs around COVID-19 vaccines and highlight a need for tailored communication strategies.

Effect of educational and financial incentive-based interventions on immunization attitudes, beliefs, intentions and receipt among close contacts of pregnant women

INTRODUCTION

Cocooning, the vaccination of close contacts of a newborn, is a strategy to limit the risk of pertussis and influenza infection among vulnerable infants.

METHODS

Pregnant women in Colorado and Georgia referred close contacts to an app that provided tailored educational videos about vaccines along with a small pharmacy-based financial incentive for vaccine receipt. The primary objective of this study was to determine the feasibility of implementing this app-based cocooning intervention.

RESULTS

Two hundred seventy seven contacts were enrolled in this study. Of those who received the educational videos, 96% found them interesting, 100% found them clear to understand, 97% found them helpful, and 99% trusted them. Completion of the videos led to significant increases in influenza vaccine knowledge (p = 0.025), Tdap vaccine knowledge (p < 0.001), and intention to receive these vaccines (p = 0.046). Of the 136 participants who reported receiving influenza vaccine, 41 (30%) reported receiving it at a pharmacy, and of the 66 who reported receiving Tdap vaccine, 15 (23%) reported receiving it at a pharmacy. Of all participants, 80% reported being comfortable receiving vaccines at a pharmacy instead of a doctor's office. The provision of small pharmacy-based financial incentives combined with individually-tailored educational videos about vaccines led to 6.97 (95%CI: 2.25-21.64) times higher odds of self-reported receipt of influenza vaccine than providing small pharmacy-based financial incentives without these videos. No significant difference was found for Tdap vaccine.

CONCLUSIONS

Tailored vaccine education can positively impact vaccine knowledge and intentions among adults. An app-based referral program providing education and financial incentives for cocooning vaccination at pharmacies is feasible.

Parental vaccine attitudes, beliefs, and practices: initial evidence in California after a vaccine policy change

Senate Bill 277 (SB277) eliminated nonmedical exemptions for school-entry vaccines in California, but the impact of parental vaccine knowledge, attitudes, and beliefs on vaccine decision-making has not been extensively examined within the post-SB277 context. This study generates preliminary understanding and discussion of the vaccination knowledge, attitudes, and beliefs among a pilot population of parents of kindergarten students in California after the implementation of SB277. School officials administered a cross-sectional survey to parents of kindergarten children in California from April to July 2019. Parents reported their perceptions of diseases and vaccines, key immunization beliefs, and confidence in different sources of vaccine information. Most parents (92%) had fully vaccinated their children post-SB277 and generally perceived vaccines to be safe and effective, but about 44% reported they were hesitant about childhood vaccines. The majority of parents (87%) rated vaccine information from their doctor as highly credible. This pilot group of kindergarten parents was generally supportive of vaccination and had fully vaccinated their children, but most parents still harbored concerns and misconceptions about vaccines and about public health authorities. This indicates a disconnect between parental vaccine compliance and confidence, and suggests that educational interventions could impact parental vaccine behavior and decision-making.

Communicating Recommendations in Public Health Emergencies: The Role of Public Health Authorities

Adherence to public health recommendations is critical for public safety and well-being. Effective and appropriate communication plays an important role in whether populations trust government and public health authorities, and the extent to which people follow public health recommendations. Poor trust in communication from public health authorities can pose significant challenges for mitigating public health emergencies and maintaining health security. This study aimed to explore the importance of trust in and understanding of communication from public health authorities in improving adherence to public health recommendations, and how that communication can be improved to develop and maintain public trust, particularly in the context of public health emergencies. To understand which factors are important for public trust in communication from public health authorities, we conducted in-depth interviews (n = 25) with a racially and demographically diverse group of individuals living in Baltimore. We found that communication source and communication transparency, such as timeliness, completeness, and clarity of information, were critical constructs of trust in communication from public health authorities. We also found that many participants misunderstood the flow of information from public health authorities to news media, and many were unaware that public health authorities provide the most reliable source of health information and recommendations during a public health emergency. To ensure adherence to public health recommendations, the public needs to trust that public health authorities are providing accurate, practical, and prudent recommendations. Drawing on these results, we provide several recommendations for developing and optimizing communication from various public health authorities.

Adapting Center for Disease Control and Prevention's immunization quality improvement program to improve maternal vaccination uptake in obstetrics

INTRODUCTION

Maternal vaccination is critical for improving maternal and child health. Quality Improvement (QI) models¹, such as the Centers for Disease Control and Prevention's (CDC) Assessment, Feedback, Incentives, eXchange (AFIX)² model, have not yet been adapted to maternal vaccinations. This study assesses the impact of AFIX-OB, an adapted version of AFIX for obstetric settings, on maternal vaccination rates.

METHODS

Between December 2016 and May 2018, state health departments and obstetric practices in Colorado and Georgia implemented the adapted AFIX-OB model. The model addressed unique patterns in patient encounters, practice flow, health records systems and competing clinical priorities in the obstetric setting through a menu of clearly-defined QI strategies, bi-weekly technical assistance meetings with designated immunization champions, incentives for champions/staff, and adapted tools to aid each practice during implementation. Vaccination rates were assessed by random chart reviews pre- and post-intervention.

RESULTS

The AFIX-OB model was evaluated in eleven obstetric practices in two states as part of a multi-level intervention to increase maternal vaccination. Post AFIX-OB implementation, documented influenza vaccination rates increased from 56% at baseline to 65% (p < 0.01); and tetanus, diphtheria, and acellular pertussis (Tdap) vaccination rates increased from 77% at baseline to 84% (p < 0.02) across all practices.

CONCLUSIONS

The AFIX-OB model showed improvement in maternal vaccination rates for both influenza and Tdap vaccines. AFIX-OB may provide a useful framework for obstetric practices, as well as for other health care specialties. The focused goal should be on broader dissemination among those interested in adopting an evidence-based model for increasing vaccine uptake.

Planning for COVID-19 vaccines safety surveillance

COVID-19 vaccines are the most important tool to stem the pandemic. They are being developed with unprecedented global collaboration and accelerated timelines to achieve WHO Emergency Use Listing, while using regulatory pathways through national regulatory authorities. Alongside preparations to ensure equitable access to the vaccines among people globally, preparations must be made within countries for COVID-19 vaccines safety surveillance on an urgent basis. Safety surveillance must be capable of investigating adverse events of special interest (AESI) and adverse events following immunization to determine a change in the benefit-risk profile of the vaccine, and to be able to anticipate coincidental events that might be attributed to the vaccine. Active surveillance systems should calculate the incidence of background rates of AESI prior to vaccine roll out. These background rates vary tremendously across regions, populations and case ascertainment methods. Active surveillance systems must be established or strengthened now, (including in LMIC), to calculate the background rates. Utilizing standardized case definitions and global standards for AESI will help in harmonization. Vaccine safety communication plans should be developed. Expanding the global vaccine safety system to meet the needs of COVID-19 and other emergency and routine use vaccines is a priority currently.

Latent Class Analysis of Maternal Vaccine Attitudes and Beliefs

Background. Maternal vaccine coverage is suboptimal, and a substantial proportion of parents have concerns about vaccines. Most parents seek out vaccine information during and immediately after their first pregnancy. No study to our knowledge has analyzed survey data to identify homogeneous groups of pregnant women based on their vaccine attitudes and beliefs. Aims. To identify homogeneity among groups of pregnant women based on their vaccine attitudes and beliefs to facilitate audience segmentation and targeting of tailored educational interventions. Method. Between June 2017 and July 2018, we surveyed 2,196 pregnant women recruited from geographically and sociodemographically diverse prenatal care practices in Georgia and Colorado. We then performed a latent class analysis to identify homogeneity among groups of pregnant women. Results. Our latent class analysis produced three groups of pregnant women: vaccine supporters (36% of women), vaccine acceptors (41%), and vaccine skeptics (23%). Discussion. The major difference between the supporters and the acceptors were whether they mostly “strongly agreed” or just “agreed” to Likert-type scale survey items assessing their vaccine attitudes and beliefs. The skeptics most frequently chose “disagree” or “don’t know” for items assessing attitudinal constructs such as confidence in vaccine safety and efficacy and disease susceptibility. However, even skeptics often chose “agree” for items assessing constructs such as disease severity and self-efficacy. Conclusions. This article provides useful insight into the homogeneity among groups of pregnant women based on their vaccine attitudes and beliefs. This knowledge should help facilitate audience segmentation and targeting of tailored educational interventions among this population.

A hidden vulnerable population: Young children up-to-date on vaccine series recommendations except influenza vaccines

Very young children (under 2 years old) have high risk for influenza-related complications. Children 6 months or older in the US are recommended to receive influenza vaccination annually, yet uptake is substantially lower than other routinely-recommended vaccines. Existing nationally-representative studies on very young child influenza vaccine uptake has several limitations: few examine provider-verified influenza vaccination (relying on parental report), few contain parental vaccine attitudes variables (known to be crucial to vaccine uptake), and none to our knowledge consider intersectionality of social disadvantage nor how influenza vaccine determinants differ from those of other recommended vaccines. This nationally-representative study examines provider-verified data on 7,246 children aged 6–23 months from the most recent (2011) National Immunization Survey to include the restricted Parental Concerns module, focusing on children up-to-date on a series of vaccines (the 4:3:1:3:3:1:4 series) but not influenza vaccines (“hidden vulnerability to influenza”). About 71% of children were up-to-date on the series yet only 33% on influenza vaccine recommendations by their second birthday; 44% had hidden vulnerability to influenza. Independent of parental history of vaccine refusal and a myriad of health services use factors, no parental history of delaying vaccination was associated with 7.5% (2.6–12.5) higher probability of hidden vulnerability to influenza despite being associated with 15.5% (10.8–20.2) lower probability of being up-to-date on neither the series nor influenza vaccines. Thus, parental compliance with broad child vaccine recommendations and lack of vaccine hesitancy may not indicate choice to vaccinate children against influenza. Examination of intersectionality suggests that maternal college education may not confer improved vaccination among non-Hispanic Black and Hispanic children despite that it does for non-Hispanic White children. Policymakers and researchers from public health, sociology, and other sectors need to collaborate to further examine how vaccine hesitancy and intersectional social disadvantage interact to affect influenza vaccine uptake in young US children.

Patient Decision Making Related to Maternal and Childhood Vaccines: Exploring the Role of Trust in Providers Through a Relational Theory of Power Approach

Immunization is one of the most effective ways to prevent infectious diseases. However, vaccination rates are suboptimal in the United States. Obstetric providers are critical in influencing vaccine decision making among pregnant women, as trust between a patient and provider may facilitate willingness to accept vaccination. Little is known about how power between a patient and provider affects vaccine acceptance. This study explored pregnant women's trust in obstetric providers within the context of vaccines. Using concepts from the relational theory of power, we conducted 40 in-depth interviews with a purposive sample of pregnant women from four Ob-Gyn practices each in Georgia and Colorado. Results suggest that to enhance trust, providers could gain distributive power by conveying empathy. Designated power through medical experience was associated with both trust and distrust, as some women trusted their providers because of their authority and medical credentials, while others viewed authority and experience as reasons to distrust their provider. To increase acceptance, providers should acknowledge the underlying power dynamics within these interpersonal relationships and strengthen rapport with patients through empathy and dialogue.

The state of vaccine safety science: systematic reviews of the evidence

This Review updates the scientific evidence assessing possible causal associations of adverse events following immunisation (AEFI) compiled in the 2012 report from the Institute of Medicine and the 2014 report from the Agency for Healthcare Research and Quality. For 12 of 46 AEFI examined, a causal relationship has been established with at least one vaccine currently routinely recommended to the general USA population: anaphylaxis, arthralgia or arthritis (mild, acute, and transient, not chronic), deltoid bursitis (when vaccine is administered improperly), disseminated varicella infection (in immune deficient individuals for whom the varicella vaccine is contraindicated), encephalitis, febrile seizures, Guillain-Barré syndrome, hepatitis (in immune deficient individuals for whom the varicella vaccine is contraindicated), herpes zoster, immune thrombocytopenic purpura, meningitis, and syncope. Other than mild acute and transient arthralgia or arthritis, which is very common in adult women after rubella vaccine, these adverse reactions are rare or very rare. Vaccines have an excellent safety profile overall and provide protection against infectious diseases to individuals and the general population.

Factors associated with referring close contacts to an app with individually-tailored vaccine information

BACKGROUND

Infants too young to be fully vaccinated are vulnerable to potentially deadly influenza and pertussis infections. The cocooning strategy limits this risk by vaccinating those likely to interact with the infant and mother during this vulnerable time, such as close friends and family members. Distribution of accurate and accessible vaccine information through existing social networks could be an important tool in increasing vaccine confidence and coverage.

METHODS

We surveyed 1095 pregnant women from diverse prenatal care practices in Georgia and Colorado. These women were surveyed through a mobile app to assess vaccine intentions, attitudes, beliefs, norms, and levels of trust, and then presented brief individually-tailored educational videos about maternal and infant vaccines and the cocooning strategy. They were then given the opportunity to refer up to six contacts to enroll in the app and receive similar vaccine education.

RESULTS

Twenty-eight percent of these women referred at least one contact, with an average of 2.67 contacts per referring woman. Most referrals (93%) were partners, parents, siblings, relatives, or close friends. Attitudinal constructs significantly associated with increased likelihood of referring contacts included: intention to receive maternal influenza vaccine, perceived safety of maternal Tdap vaccine, perceived efficacy of maternal influenza vaccine, perceived susceptibility to and severity of influenza during pregnancy, and trust in vaccine information from the Centers for Disease Control and Prevention (CDC) and academic institutions. Uncertainty about infant vaccine intentions was associated with decreased likelihood of referring contacts.

CONCLUSIONS

Pregnant women who valued vaccination and trusted vaccine information from academic institutions were more likely to refer an educational app about vaccines than those who did not. Further research is needed to determine the potential impact of this strategy on vaccine coverage when implemented on a large scale.

TRIAL REGISTRATION

The survey informing this article was part of a randomized controlled trial funded by the National Institutes of Health [clinicaltrials.gov registration number NCT02898688].

Characterizing the vaccine knowledge, attitudes, beliefs, and intentions of pregnant women in Georgia and Colorado

Vaccine coverage for maternal vaccines is suboptimal; only about half of pregnant women received influenza and Tdap vaccines in 2018. We explored knowledge, attitudes, beliefs, intentions, and trust regarding maternal and infant vaccines among pregnant women. Between June 2017 and July 2018, we surveyed 2196 pregnant women recruited from geographically and socio-demographically diverse prenatal care practices in Georgia and Colorado (56% response rate). Fifty-six percent of pregnant women intended to receive both influenza and Tdap vaccines during pregnancy and 68% intended to vaccinate their baby with all recommended vaccines on time. Attitudinal constructs associated with intention to vaccinate include confidence in vaccine safety (ORs: 16–38) and efficacy (ORs: 4–19), perceived risk of vaccine-preventable diseases (ORs: 2–6), social norms (ORs: 4–10), and trust in sources of vaccine information. Women pregnant with their first child were less likely than women who had prior children to intend to vaccinate themselves and their children, more likely to be unsure about their intentions to receive both maternal and infant vaccines, and less likely to report feeling they had enough knowledge or information about vaccines and vaccine safety (p < .01). This demonstrates an opportunity for vaccine education to increase vaccine confidence and informed decision-making, especially among first-time pregnant women.

MomsTalkShots: An individually tailored educational application for maternal and infant vaccines

INTRODUCTION

The development and initial assessment in a clinical setting of a theory-driven, individually tailored educational application (app), MomsTalkShots, focused on increasing uptake of maternal and infant vaccines is described.

METHODS

MomsTalkShots algorithmically tailored videos based on parent needs to deliver an intervention that was specifically responsive to individual vaccine attitudes, beliefs and intentions, demographics, and source credibility. MomsTalkShots was evaluated among 1103 pregnant women recruited from 23 geographically and socio-demographically diverse obstetrician-gynecologist offices in Georgia and Colorado in 2017. Self-reported information needs were assessed pre-and post-videos and participants self-reported factors related to usability and analyzed in 2018.

RESULTS

The vast majority of women reported MomsTalkShots was helpful (95%), trustworthy (94%), interesting (97%) and clear to understand (99%), none of which varied by demographics or parity. Reported usability was slightly lower among vaccine hesitant women, yet the majority reported MomsTalkShots was helpful (91%), trustworthy (85%), interesting (97%) and clear (99%). The majority of women (72%) who did not have enough vaccine information pre-videos reported enough information post-videos.

CONCLUSIONS

MomsTalkShots was designed to provide individually tailored vaccine information to pregnant women from a population with varied vaccine intentions, confidence and vaccine concerns. MomsTalkShots was extremely well-received among pregnant women, even among women who were initially vaccine hesitant and did not intend to vaccinate themselves and their infants according to the recommended immunization schedule. Next steps include evaluation to assess impact on vaccine uptake and expansion to adolescent and adult vaccines.

Associations of Statewide Legislative and Administrative Interventions With Vaccination Status Among Kindergartners in California

IMPORTANCE

California implemented 3 interventions to increase uptake of vaccines. In 2014, Assembly bill 2109 tightened requirements for obtaining a personal belief exemption. A 2015 campaign provided educational materials to school staff on the proper application of conditional admission for kindergartners who were not up to date on required vaccinations. In 2016, Senate bill 277 eliminated personal belief exemptions. Prior research has not evaluated these 3 interventions together with regard to the vaccination status of students.

OBJECTIVE

To assess the changes in the yearly rates of kindergartners who were not up to date on required vaccinations who were entering school during the period of the interventions, by focusing on geographic clustering and the potential contacts of these kindergartners.

DESIGN, SETTING, AND PARTICIPANTS

Observational study that used cross-sectional school-entry data from 2000-2017 to calculate the rates of kindergartners attending California schools who were not up to date on required vaccinations.

EXPOSURES

Assembly bill 2109, a conditional admission education program, and Senate bill 277.

MAIN OUTCOMES AND MEASURES

The primary outcome was the yearly rate of kindergartners without up-to-date vaccination status. The secondary outcomes were (1) the modified aggregation index, which was used to assess the potential within-school contacts among kindergartners without up-to-date vaccination status, (2) the number of geographic clusters of schools with rates for kindergartners without up-to-date vaccination status that were higher than the rates for schools located outside the cluster, and (3) the number of schools located inside the geographic clusters.

RESULTS

In California between 2000 and 2017, 9 323 315 children started attending kindergarten and 721 593 were not up to date on required vaccinations. Prior to the interventions, the statewide rate of kindergartners without up-to-date status for required vaccinations increased from 7.80% during 2000 to 9.84% during 2013 and then decreased after the interventions to 4.87% during 2017. The percentage chance for within-school contact among kindergartners without up-to-date vaccination status decreased from 26.02% during 2014 to 4.56% (95% CI, 4.21%-4.99%) during 2017. During 2012-2013, there were 124 clusters that contained 3026 schools with high rates of kindergartners without up-to-date vaccination status. During 2014-2015, there were 93 clusters that contained 2290 schools with high rates of kindergartners without up-to-date vaccination status. During 2016-2017, there were 110 clusters that contained 1613 (95% CI, 1565-1691) schools.

CONCLUSIONS AND RELEVANCE

In California, statewide legislative and educational interventions were associated with a decrease in the yearly rates of kindergartners without up-to-date vaccination status. These interventions also were associated with reductions in the number of schools inside the clusters with high rates of kindergartners without up-to-date vaccination status and the potential for contact among these kindergartners.

Elimination of Nonmedical Immunization Exemptions in California and School-Entry Vaccine Status

BACKGROUND AND OBJECTIVES

California implemented Senate Bill 277 (SB277) in 2016, becoming the first state in nearly 30 years to eliminate nonmedical exemptions from immunization requirements for schoolchildren. Our objectives were to determine (1) the impacts of SB277 on the percentage of kindergarteners entering school not up-to-date on vaccinations and (2) if geographic patterns of vaccine refusal persisted after the implementation of the new law.

METHODS

At the state level, we analyzed the magnitude and composition of the population of kindergarteners not up-to-date on vaccinations before and after the implementation of SB277. We assessed correlations between previous geographic patterns of nonmedical exemptions and patterns of the remaining entry mechanisms for kindergarteners not up-to-date after the law's implementation.

RESULTS

In the first year after SB277 was implemented, the percentage of kindergartners entering school not up-to-date on vaccinations decreased from 7.15% to 4.42%. The conditional entrance rate fell from 4.43% to 1.91%, accounting for much of this decrease. Other entry mechanisms for students not up-to-date, including medical exemptions and exemptions for independent study or homeschooled students, largely replaced the decrease in the personal belief exemption rate from 2.37% to 0.56%. In the second year, the percentage of kindergartners not up-to-date increased by 0.45%, despite additional reductions in conditional entrants and personal belief exemptions. The correlational analysis revealed that previous geographic patterns of vaccine refusal persisted after the law's implementation.

CONCLUSIONS

Although the percentage of incoming kindergarteners up-to-date on vaccinations in California increased after the implementation of SB277, we found evidence for a replacement effect.

Development and acceptability of a video-based vaccine promotion tutorial for obstetric care providers

A prenatal care provider's recommendation for maternal vaccines is one of the strongest predictors of vaccine acceptance during pregnancy. Aside from basic talking points, few resources exist to help obstetric care providers effectively navigate conversations with vaccine hesitant patients. This paper describes the development and acceptability of "VaxChat," an hour-long, evidence-based video tutorial aimed at improving obstetric care providers' ability to promote maternal vaccines. Between June and November 2017, 62 obstetric care providers registered to receive continuing medical education credit for viewing VaxChat. Of the post-tutorial responses received, over 90% said VaxChat increased their knowledge of what to say to vaccine hesitant patients, increased their confidence in addressing vaccinations with their pregnant patients, and will help them improve their practice culture regarding maternal vaccine promotion. Eighty percent intend to change how they approach vaccine conversations. These data suggest VaxChat may be a welcome complement to existing provider-to-patient talking points.

Vaccination perspectives among adolescents and their desired role in the decision-making process

Background: To assess the knowledge and attitudes of middle school students toward vaccination, we measured their understanding of vaccine safety and effectiveness, expectations for communication with heath care providers, and their desired role in the vaccination decision-making process. Methods: A cross-sectional, self-administered survey was conducted among seventh and eighth grade students in a middle school in Upstate New York. Bivariate analyses were conducted to identify differences in perspective by gender, grade, and attitudes toward vaccination. Results: Of 346 students attending class, 336 (97.1%) participated. The majority of respondents were White (71.3%) and 11 to 13 years of age (78.2%). Boys were significantly more likely than girls to perceive vaccines to be very safe (48.4% vs 30.2%, p < 0.01) and very effective (49.7% vs 29.0%, p < 0.01). Approximately one-third of adolescents reported having a say in the decision to be vaccinated and a quarter of students expressed a desire for specific information about vaccines. Conclusions: This study found that young adolescents in a nonurban area of Upstate New York were generally marginalized in the vaccine decision-making process yet third of them indicated an interest in how vaccines work and a desire to participate in healthcare decisions. Interventions to improve vaccine uptake among adolescents should capitalize on this desire to understand vaccine safety, effectiveness and mechanism of action.

Child Influenza Vaccination and Adult Work Loss: Reduced Sick Leave Use Only in Adults With Paid Sick Leave

INTRODUCTION

Children are a population of interest for influenza. They are at increased risk for severe influenza, comprise a substantial portion of influenza morbidity, and significantly contribute to its transmission in the household and subsequent parental work loss. The association between influenza vaccination and work loss prevention, however, has rarely been studied, and the sparse existing literature has very limited generalizability to U.S. adults, thus requiring better characterization.

METHODS

Using pooled National Health Interview Survey data (2013-2015, analyses conducted in 2018) nationally representative of working U.S. adults with household children (n=23,014), zero-inflated negative binomial regression examined the association of child influenza vaccination (exposure) with sick days (outcome) stratified by paid sick leave (no: n=10,741, yes: n=12,273).

RESULTS

Child influenza vaccination was associated with significantly lower sick day usage, but only among adults with paid sick leave (prevalence rate ratio=0.79, 95% CI=0.67, 0.93), equating to average annual sick days of 4.07 vs 3.29 in adults with unvaccinated versus vaccinated household children (difference=0.78 fewer days annually).

CONCLUSIONS

Influenza vaccination of children is associated with reduced sick leave in household adults, helping to keep the workforce healthy and reduce influenza's costly annual economic burden. This only occurred among adults with paid sick leave, however, which is distributed inequitably by income, education, gender, occupation, and race/ethnicity. Health in All Policies considers downstream health effects of social and economic policy; the failure of federal policy to ensure paid sick leave likely contributes to propagating influenza and health inequities.

Enhancing uptake of influenza maternal vaccine

INTRODUCTION

Influenza vaccination during pregnancy can offer many benefits to both mother and infant. Despite recommendations from the Advisory Committee on Immunization Practices, vaccine coverage rates among pregnant women during pregnancy are below 40% in the United States. There is a need for a greater understanding of what interventions can improve vaccine uptake among pregnant women.

AREAS COVERED

This review synthesizes the existing evidence on the effectiveness of interventions to improve maternal influenza vaccine uptake. These interventions are examined within the framework of the three psychological propositions: thoughts and feelings, social processes and changing behavior directly.

EXPERT COMMENTARY

A number of promising and effective interventions were identified in this review. Nudge-based interventions that build on favorable intentions to vaccinate such as provider prompts and standing orders have demonstrated significant success in improving influenza vaccine uptake. However, substantial gaps in the literature still exist. Provider recommendations are the most important predictor of vaccine receipt among pregnant women, yet few studies evaluated intervening to improve the dialogue between patient and provider. With the potential for even more vaccines to be added to the maternal immunization schedule, it is vitally important to understand how to improve uptake.

Exploring California's new law eliminating personal belief exemptions to childhood vaccines and vaccine decision-making among homeschooling mothers in California

BACKGROUND

California's Senate Bill 277 (SB-277) law eliminated the personal belief exemption to school immunization requirements. A potential consequence may be that parents choose homeschooling to avoid immunization. Vaccine attitudes and behaviors have not been well studied among the home-schooling population. This study explored the effect of SB-277 and vaccine decision-making among California home schoolers.

METHODS

Purposive and snowball sampling were used recruit home-schooling parents through home-schooling Facebook groups based on home school type in high-exemption regions in California for in-depth interviews. Participants had to have a child in a legalized form of homeschooling in California in grades kindergarten-twelfth grade.

RESULTS

Twenty-four mothers were interviewed. Participants were categorized based on self-reported vaccine attitudes and behavior into three groups: Confident and Accepting, Hesitant and Accepting, and Skeptical and Refusing. All reported the belief that SB-277 is an infringement on parental rights but was not currently impacting them. Confident and Accepting mothers (n = 10) generally believed vaccinations were safe, effective, and posed a lower risk than vaccine preventable disease (VPD). Hesitant and Accepting mothers (n = 5) expressed varying confidence levels in the belief that vaccinations were safe and effective, were not confident in the belief that vaccination posed lower risks than VPD risk, and risk perception affected vaccine decision-making. Skeptical and Refusing mothers (n = 9) generally believed that vaccinations were unsafe and ineffective, refused select vaccines, believed that vaccination posed a more serious risk than VPD risks, and belief of vaccine harm was a salient factor in vaccine decision-making.

CONCLUSION

Home-schooling mothers were concerned about SB-277 but did not report that it was directly impacting their children, their vaccine decisions, or reason to home school. Vaccine attitudes and beliefs among homeschooling mothers broadly fell into categories similar to parents of non-home-schooled children. Future quantitative studies should measure vaccine hesitancy and refusal prevalence and potential confounders.

Practice-, Provider-, and Patient-level interventions to improve preventive care: Development of the P3 Model

For adequate provision of preventive services, there is an interplay between activities at the healthcare practice, healthcare provider, and patient levels of the clinical encounter. Commonly used health promotion and behavior theoretical models address some of these three levels, but none fully account for all three. Building off of key components of many existing theoretical models, including the Health Belief Model, Theory of Planned Behavior/Theory of Reasoned Action, Social Cognitive Theory, Social Ecological Model, and the Systems Model of Clinical Preventive Care, we describe the development of the P3 (Practice-, Provider-, and Patient-level) Model for preventive care interventions. The P3 Model accounts for all three levels of the clinical encounter, and the factors that impact these levels, concurrently. This yields a model for preventive care that is applicable and adaptable to different settings, and that provides a framework for the development, implementation, and evaluation of preventive care promotion interventions. The applicability of the P3 Model is shown through two exemplar preventive care programs – immunization and colorectal cancer screening. The P3 Model allows interventions to be developed and evaluated in a modular approach, to allow more practical refinement and optimization of the intervention.