101
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McNeil DA, Mueller M, MacDonald S, McDonald S, Saini V, Kellner JD, Tough S. Maternal perceptions of childhood vaccination: explanations of reasons for and against vaccination. BMC Public Health 2019; 19:49. [PMID: 30630511 PMCID: PMC6327385 DOI: 10.1186/s12889-018-6338-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 12/17/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Understanding reasons for and against vaccination from the parental perspective is critical for designing vaccination campaigns and informing other interventions to increase vaccination uptake in Canada. The objective of this study was to understand maternal vaccination decision making for children. METHODS Mothers participating in a longitudinal community-based pregnancy cohort, the All Our Babies study in Calgary, Alberta, completed open-ended survey questions providing explanations for the vaccination status of their child by 24 months postpartum. Qualitative responses were linked to administrative vaccination records to examine survey responses and recorded child vaccination status. RESULTS There were 1560 open-ended responses available; 89% (n = 1391) provided explanations for vaccinating their children, 5% (n = 79) provided explanations for not vaccinating/delaying, and 6% (n = 90) provided explanations for both. Themes were similar for those vaccinating and not vaccinating/delaying; however, interpretations were different. Two broad themes were identified: Sources of influence and Deliberative Processes. Sources of influence on decision making included personal, family, and external experiences. Deliberative Processes included risk, research, effectiveness, and balancing risks/benefits. Under Deliberative Processes, responsibility was a category for those vaccinating; while choice, instrumental/practical, and health issues were categories for those not vaccinating/delaying. Mothers' levels of conviction and motivation provided a Context for understanding their decision making perspectives. CONCLUSIONS Vaccination decision making is complex and impacted by many factors that are similar but contribute to different decisions depending on mothers' perspectives. The results of this study indicate the need to examine new intervention approaches to increase uptake that recognize and address feelings of pressure and parental commitment to choice.
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Affiliation(s)
- Deborah A McNeil
- Maternal Newborn Child and Youth Strategic Clinical Network, Alberta Health Services, Calgary, Alberta, Canada.,University of Calgary, Faculty of Nursing and Cumming School of Medicine Department of Community Health Sciences, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
| | - Melissa Mueller
- Research and Innovation, Population Public and Indigenous Health, Alberta Health Services, Southport Atrium, 10101 Southport Road S.W, Calgary, Alberta, T2W 3N2, Canada.
| | - Shannon MacDonald
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada.,Cumming School of Medicine, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Sheila McDonald
- Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada.,Research and Innovation, Population Public and Indigenous Health, Alberta Health Services, Southport Atrium, 10101 Southport Road S.W, Calgary, Alberta, T2W 3N2, Canada.,Departments of Pediatrics and Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Vineet Saini
- Research and Innovation, Population Public and Indigenous Health, Alberta Health Services, Southport Atrium, 10101 Southport Road S.W, Calgary, Alberta, T2W 3N2, Canada.,University of Calgary Faculty of Veterinary Medicine, Calgary, Alberta, Canada
| | - James D Kellner
- Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada.,Departments of Pediatrics and Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Suzanne Tough
- Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada.,Cumming School of Medicine, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
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102
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Arora G, Lehman D, Charlu S, Ross N, Ardy A, Gordon B, Pannaraj PS. Vaccine health beliefs and educational influences among pediatric residents. Vaccine 2019; 37:857-862. [PMID: 30611603 DOI: 10.1016/j.vaccine.2018.12.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 12/15/2018] [Accepted: 12/18/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE A pilot study of pediatric residents to describe perceived benefits and effects of vaccines and educational influences on vaccine practice among pediatric residents. STUDY DESIGN Eighty-seven residents, from two institutions in a region with relatively high vaccine hesitancy, responded to a survey conducted in 2014-2015. RESULTS Residents identified professional experiences with vaccine preventable diseases (VPDs) and observing pediatricians as most impactful to their vaccine beliefs. Residents who had observed pediatric faculty agreeing to alternative or delayed vaccinations were more likely to believe this to be acceptable vaccine practice (70.1% vs. 21.1%, χ2 = 17.778, p < 0.001). Most residents (68 [79.1%]) reported feeling confident in their ability to discuss vaccines. CONCLUSIONS Pediatricians must be equipped with accurate vaccine health beliefs to impact parental vaccine hesitancy. This study identifies important gaps in medical education, with pediatric residents reporting limitations in their professional experience with VPDs and high rates of observing alternative vaccination practice.
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Affiliation(s)
- Gitanjli Arora
- Department of Pediatrics, Children's Hospital Los Angeles, United States.
| | - Deborah Lehman
- Department of Pediatrics, University of California Los Angeles, United States
| | - Sandhya Charlu
- Department of Pediatrics, Children's Hospital Los Angeles, United States
| | - Nicole Ross
- Department of Pediatrics, Children's Hospital Los Angeles, United States
| | - Adriana Ardy
- Department of Pediatrics, Children's Hospital Los Angeles, United States
| | - Bahareh Gordon
- Department of Pediatrics, University of California Los Angeles, United States
| | - Pia S Pannaraj
- Department of Pediatrics, Children's Hospital Los Angeles, United States; Department of Molecular Microbiology and Immunology, University of Southern California, United States
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103
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Topçu S, Almış H, Başkan S, Turgut M, Orhon FŞ, Ulukol B. Evaluation of Childhood Vaccine Refusal and Hesitancy Intentions in Turkey. Indian J Pediatr 2019; 86:38-43. [PMID: 29855996 DOI: 10.1007/s12098-018-2714-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 05/15/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess the factors affecting parental childhood vaccine refusal and hesitancy (CVRH) intentions in Turkey. METHODS A total of 33 children's parents who were referred to two different child health care clinics because of CVRH and 99 controls were enrolled into this study from November through December 2017. The socio-demographic characteristics and perceptions of the parents who refused at least one vaccine for their child/children were compared with controls. RESULTS The monthly household income was significantly lower in CVRH group than control group. Refusal of the heel stick, refusal of hearing test, not using baby car seat, irregular use of vitamin D and iron prophylaxis, using alterative/complementary medicine, distrust in vaccines were the parameters which were found significantly higher in refused vaccine group than in control group. The beliefs "It may be dangerous for children" and "Distrust to the vaccines" were the most determined factors with a ratio of 51.5% in CVRH group. CONCLUSIONS This is the first study conducted to investigate the social-demographic characteristics and perception of parental CVRH in Turkey. The beliefs "It may be dangerous for the children" and "Distrust the vaccines" were the most determined factors which may affect CVRH. Some child health protective strategies were less undertaken in CVRH group than in controls; including heel stick test, hearing test, using baby car seat and using of Vitamin D and iron prophylaxis. The parents who have CVRH intentions tend to behave irresponsibly in care of their children.
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Affiliation(s)
- Seda Topçu
- Division of Social Pediatrics, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey.
| | - Habip Almış
- Department of Pediatrics, Adıyaman University School of Medicine, Adıyaman, Turkey
| | - Sevgi Başkan
- Division of Social Pediatrics, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
| | - Mehmet Turgut
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Adıyaman University School of Medicine, Adıyaman, Turkey
| | - Filiz Şimşek Orhon
- Division of Social Pediatrics, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
| | - Betül Ulukol
- Division of Social Pediatrics, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
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104
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Kraśnicka J, Krajewska-Kułak E, Klimaszewska K, Cybulski M, Guzowski A, Kowalewska B, Jankowiak B, Rolka H, Doroszkiewicz H, Kułak W. Mandatory and recommended vaccinations in Poland in the views of parents. Hum Vaccin Immunother 2018; 14:2884-2893. [PMID: 30257128 DOI: 10.1080/21645515.2018.1496766] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Background: Vaccinations are currently the key element in the prevention of the spread of infectious diseases. We studied parents' opinions about mandatory and recommended preventive vaccinations in Poland. Methods: A diagnostic survey using an original questionnaire was done in a group of 300 parents. Results: A total of 3.7% of parents did not vaccinate their children. 90% were aware of the threat potentially posed by infectious diseases, and 73.7% knew that breastfeeding alone does not ensure sufficient protection against them. 28% believed that it is necessary to vaccinate a child against all diseases, 51.7% that the number of vaccinations is insufficient, and 62.7% that vaccine use is safe. 40.7% thought that unvaccinated children should not be able to attend nurseries and kindergartens, as they pose a threat to other children. Postvaccinal adverse events occurred in 21.3% of children, mainly (71.9%) an increase in body temperature above 38°C. 88.3% were informed about possible vaccine-induced complications, most often by nurses (79.7%). 88% of the respondents were aware of the possibility to switch to an alternative immunization program, 92% were informed on the possible administration of recommended vaccines, and 53% took advantage of combined vaccines. Conclusions: Views on vaccinations were mostly varied, depending on the age, sex, education, and financial situation of the respondents. Most of the parents who did not vaccinate their children believed that immunity can be acquired by infection. They were in favor of a limited number of vaccinations, were more critical of the vaccination program in Poland, considered the vaccines used in Poland to be unsafe, and blamed vaccines for multiple developmental defects and autism in children. Parents whose children experienced vaccine-induced adverse reactions were more likely to have doubts before the next vaccination.
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Affiliation(s)
- Jolanta Kraśnicka
- a Family Doctors Clinic "Pro Medica Centrum" in Białystok , Białystok , Poland
| | | | - Krystyna Klimaszewska
- b Department of Integrated Medical Care , Medical University of Bialystok , Białystok , Poland
| | - Mateusz Cybulski
- b Department of Integrated Medical Care , Medical University of Bialystok , Białystok , Poland
| | - Andrzej Guzowski
- b Department of Integrated Medical Care , Medical University of Bialystok , Białystok , Poland
| | - Beata Kowalewska
- b Department of Integrated Medical Care , Medical University of Bialystok , Białystok , Poland
| | - Barbara Jankowiak
- b Department of Integrated Medical Care , Medical University of Bialystok , Białystok , Poland
| | - Hanna Rolka
- b Department of Integrated Medical Care , Medical University of Bialystok , Białystok , Poland
| | - Halina Doroszkiewicz
- c Department of Geriatrics , Medical University of Bialystok , Białystok , Poland
| | - Wojciech Kułak
- d Department of Pediatric Rehabilitation , Medical University of Bialystok , Białystok , Poland
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105
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Vyas D, Galal SM, Rogan EL, Boyce EG. Training Students to Address Vaccine Hesitancy and/or Refusal. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2018; 82:6338. [PMID: 30425397 PMCID: PMC6221531 DOI: 10.5688/ajpe6338] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 08/02/2017] [Indexed: 05/26/2023]
Abstract
Objective. To determine the impact of a vaccine hesitancy learning unit on student knowledge, attitudes, and ability to address vaccine hesitancy and/or refusal. Methods. The learning unit consisted of two standardized patient simulation encounters performed one week apart. A 13-item attitudes survey was administered prior to the simulations to determine student confidence and knowledge regarding vaccine hesitancy. Students then participated in an encounter with a simulated patient who assessed the students' abilities using a 16-item grading rubric related to the art of the rhetoric, communication skills, and social, emotional competence. Post-simulation, students received feedback, completed a self-reflection exercise, and received formal coursework on addressing vaccine hesitancy. The following week, students participated in a second simulated patient encounter and thereafter completed the same attitudes and satisfaction surveys. Results. There were 203 students who went through the learning unit, with 180 (88.6% response rate) completing all the survey tools. The results showed significant improvements in all 16 items of the assessment rubric. On the pre/post attitudes questions, 9 out of 13 items showed significant improvement. Gains were largest for knowledge on the use of thimerosal as a preservative, speaking about how vaccines will not overwhelm a child's immune system, and knowledge about vaccinations not overwhelming a child's immune system. Overall, 94% of students were satisfied with the learning unit. Conclusion. This learning unit was effective in improving student confidence and ability to address vaccine hesitancy.
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Affiliation(s)
- Deepti Vyas
- University of the Pacific, Thomas J. Long School of Pharmacy and Health Sciences, Stockton, California
| | - Suzanne M Galal
- University of the Pacific, Thomas J. Long School of Pharmacy and Health Sciences, Stockton, California
| | - Edward L Rogan
- University of the Pacific, Thomas J. Long School of Pharmacy and Health Sciences, Stockton, California
| | - Eric G Boyce
- University of the Pacific, Thomas J. Long School of Pharmacy and Health Sciences, Stockton, California
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106
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Hofstetter AM, Simon TD, Lepere K, Ranade D, Strelitz B, Englund JA, Opel DJ. Parental Vaccine Hesitancy and Declination of Influenza Vaccination Among Hospitalized Children. Hosp Pediatr 2018; 8:628-635. [PMID: 30228245 DOI: 10.1542/hpeds.2018-0025] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Parents frequently decline the influenza vaccine for their child during hospitalization. In this study, we aimed to assess the role of vaccine hesitancy in these declinations. METHODS This cross-sectional survey study was conducted among English-speaking parents of influenza vaccine-eligible children who were hospitalized between October 2014 and April 2015. Between July 2015 and September 2015, parents were recruited via mail to complete the validated Parent Attitudes about Childhood Vaccines (PACV) survey (modified for influenza vaccination). PACV scores (0-100 scale) were dichotomized into scores of ≥50 (hesitant) and <50 (nonhesitant). The primary outcome was parental declination of the influenza vaccine for their child during hospitalization. A secondary outcome was the declination reason documented during hospitalization. The main independent variable was parental vaccine hesitancy status, determined by the PACV score. Multivariable logistic regression was used to examine the association between vaccine hesitancy and influenza vaccine declination, adjusting for sociodemographic, visit, and clinical characteristics. The relationship between vaccine hesitancy and declination reason was also explored. RESULTS Of 199 parents (18% response rate), 24% were vaccine hesitant and 53% declined the influenza vaccine for their child during hospitalization. Vaccine hesitancy (versus nonhesitancy) was associated with declining influenza vaccination (adjusted odds ratio: 6.4; 95% confidence interval: 2.5-16.5). The declination reason differed by vaccine hesitancy status, with a higher proportion of parents who were hesitant versus nonhesitant reporting "vaccine concern" or "vaccine unnecessary." CONCLUSIONS Vaccine hesitancy was prevalent in this limited sample of parents of hospitalized children and associated with influenza vaccine declination. Additional investigation in a large, diverse, prospectively recruited cohort is warranted given the potential sampling bias present in this study.
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Affiliation(s)
- Annika M Hofstetter
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; and
- Seattle Children's Research Institute, Seattle, Washington
| | - Tamara D Simon
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; and
- Seattle Children's Research Institute, Seattle, Washington
| | | | - Daksha Ranade
- Seattle Children's Research Institute, Seattle, Washington
| | | | - Janet A Englund
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; and
- Seattle Children's Research Institute, Seattle, Washington
| | - Douglas J Opel
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; and
- Seattle Children's Research Institute, Seattle, Washington
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107
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Fuzzell LN, LaJoie AS, Smith KT, Philpott SE, Jones KM, Politi MC. Parents' adherence to pediatric health and safety guidelines: Importance of patient-provider relationships. PATIENT EDUCATION AND COUNSELING 2018; 101:1570-1576. [PMID: 29731179 PMCID: PMC6057837 DOI: 10.1016/j.pec.2018.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 04/27/2018] [Accepted: 05/01/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To examine 1) parent-provider communication about pediatric health/safety guidelines, 2) trust in child's provider, 3) comfort discussing guidelines, 4) agreement with guideline advice, 5) self-efficacy following guidelines, and their impact on guideline adherence. METHOD 256 parents of children ages 0-6 completed an online survey about sunscreen use, newborn Vitamin K injections, influenza vaccination, routine vaccination, car seats, infant safe sleep, furniture anchoring, large trampoline use, and firearm safety. Multivariable models regressed: 1) communication about each guideline on parents' corresponding guideline adherence; 2) trust, comfort discussing guidelines, agreement with guideline advice, self-efficacy, on parents' total guideline adherence. RESULTS Communication about furniture anchoring (OR = 2.26), sunscreen (OR = 5.28), Vitamin K injections (OR = 3.20), influenza vaccination (OR = 13.71), routine vaccination (OR = 6.43), car seats (OR = 6.15), and infant safe sleep (OR = 3.40) related to corresponding guideline adherence (ps < 0.05). Firearm safety communication was not related to adherence (OR = 1.11, n.s.). Trampoline communication related to lower likelihood of trampoline guideline adherence (OR = 0.24, p = 0.001). Agreement with guideline advice (β = 0.35), trust (β = 0.34), self-efficacy (β = 0.45), comfort discussing guidelines (β = 0.35) positively related to total guideline adherence (ps < 0.001). CONCLUSION Findings underscore the importance of provider communication about health/safety guidelines. PRACTICE IMPLICATIONS Providers should respectfully engage and build relationships with parents to support health/safety guideline adherence.
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Affiliation(s)
- Lindsay N Fuzzell
- Washington University in St. Louis, School of Medicine, Division of Public Health Sciences, St. Louis, MO, USA.
| | - A Scott LaJoie
- University of Louisville, Public Health and Information Sciences, Louisville, KY, USA
| | - Kyle T Smith
- Washington University in St. Louis, School of Medicine, Division of Public Health Sciences, St. Louis, MO, USA
| | - Sydney E Philpott
- Washington University in St. Louis, School of Medicine, Division of Public Health Sciences, St. Louis, MO, USA
| | - Katherine M Jones
- Washington University in St. Louis, School of Medicine, Department of Pediatrics, St. Louis, MO, USA
| | - Mary C Politi
- Washington University in St. Louis, School of Medicine, Division of Public Health Sciences, St. Louis, MO, USA
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108
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Coley S, Hoefer D, Rausch-Phung E. A population-based reminder intervention to improve human papillomavirus vaccination rates among adolescents at routine vaccination age. Vaccine 2018; 36:4904-4909. [PMID: 30037480 DOI: 10.1016/j.vaccine.2018.06.056] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 06/18/2018] [Accepted: 06/26/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Public health authorities have the resources to conduct efficient immunization reminder interventions to improve vaccine uptake. The objective of this initiative was to design and implement a cost-effective centralized HPV vaccine reminder using New York State Immunization Information System data as one of five prespecified activities to increase initiation and completion among 11- to 13-year-old adolescents. METHODS The New York State Department of Health sent reminder letters to the parents or guardians of eligible adolescents who were due for the first dose of HPV vaccine and observed HPV vaccine administration in the six months after each mailing. Subjects were randomized into an intervention group, mailed on May 14, 2015 and a control group, mailed on December 8, 2015. RESULTS The analysis consisted of 81,558 eligible letter recipients. Letter recipients were 2 percent more likely to initiate vaccination than control subjects. Significant increases in vaccine uptake were observed for all age and gender strata. The intervention cost was $30.95 for each adolescent who initiated the HPV vaccine series. New York State Department of Health received far less public feedback, including negative feedback, about this intervention that was originally anticipated. CONCLUSIONS Public health entities can effectively utilize existing resources to conduct large-scale reminder interventions targeting a jurisdiction's entire 11- to 13-year-old population.
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Affiliation(s)
- Scott Coley
- New York State Department of Health, Corning Tower, Empire State Plaza, Albany, NY 12237, United States.
| | - Dina Hoefer
- New York State Department of Health, Corning Tower, Empire State Plaza, Albany, NY 12237, United States
| | - Elizabeth Rausch-Phung
- New York State Department of Health, Corning Tower, Empire State Plaza, Albany, NY 12237, United States
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109
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Head KJ, Biederman E, Sturm LA, Zimet GD. A retrospective and prospective look at strategies to increase adolescent HPV vaccine uptake in the United States. Hum Vaccin Immunother 2018; 14:1626-1635. [PMID: 29359986 PMCID: PMC6067847 DOI: 10.1080/21645515.2018.1430539] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 12/20/2017] [Accepted: 01/15/2018] [Indexed: 01/06/2023] Open
Abstract
The HPV vaccine debuted more than ten years ago in the United States and many strategies have been evaluated to increase HPV vaccination rates, which include not only improving current vaccination behaviors but also sustaining these behaviors. Researchers and practitioners from a variety of backgrounds have engaged in this work, which has included efforts directed at public health and government policies, health education and health promotion programs, and clinical and patient-provider approaches, as well as work aimed to respond to and combat anti-HPV vaccination movements in society. Using a previously developed conceptual model to organize and summarize each of these areas, this paper also highlights the need for future HPV vaccine promotion work to adopt a multi-level and, when possible, integrated approach in order to maximize impact on vaccination rates.
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Affiliation(s)
- Katharine J. Head
- Department of Communication Studies, Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA
| | | | - Lynne A. Sturm
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Gregory D. Zimet
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
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110
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Pottinger HL, Jacobs ET, Haenchen SD, Ernst KC. Parental attitudes and perceptions associated with childhood vaccine exemptions in high-exemption schools. PLoS One 2018; 13:e0198655. [PMID: 29902199 PMCID: PMC6002085 DOI: 10.1371/journal.pone.0198655] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 05/21/2018] [Indexed: 11/21/2022] Open
Abstract
Previous work demonstrates that individuals who obtain exemptions from school immunization requirements are geographically clustered, making regional differences in vaccination coverage a significant concern. Even where exemption levels are high, there are still parents that vaccinate. School-level assessments have determined that exemptors are more likely to attend wealthier schools with fewer minorities. Few studies have assessed divergent opinions within the context of a higher-exemption community to examine subtle differences in opinion surrounding vaccinations. Therefore, the objective of this work was to assess attitudes and perceptions towards vaccinations and compare them for exemptors and non-exemptors. We administered surveys to parents in high-exemption (>10%) elementary schools in Arizona during the 2012–13 school year. A total of 404 surveys were completed by parents among schools in Maricopa (n = 7) and Yavapai (n = 2) counties. Of these, 35% (n = 141) were exemptors and 65% (n = 261) were non-exemptors. Exemptors were more likely than non-exemptors to be concerned about serious side-effects (p<0.001). They were more likely to report knowing someone who had been diagnosed with a vaccine-preventable disease (p<0.001) but less likely to report that this had been a serious illness in that person (p<0.001) and they believed it is better for a child to develop immunity through illness than vaccination (p<0.001). They were less likely to trust physicians (p<0.001) and information about vaccines (p<0.001) and were more likely to obtain their health care from a naturopath (p<0.001). In summary, exemptors in these Arizona schools do not appear to be exempting their children from vaccinations due to convenience, as has been hypothesized in other settings. Based on the divergent views within high-exemption schools and reported distrust of the medical establishment, target interventions for high-exemption schools are discussed. Additionally, given the lack of effective non-policy based interventions to-date, the negligible declines in personal belief exemption rates, and vaccine preventable disease rate increases in Arizona, especially in high-exemption areas, legislative action in Arizona may also warrant further investigation.
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Affiliation(s)
- Heidi L. Pottinger
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, United States of America
- * E-mail:
| | - Elizabeth T. Jacobs
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, United States of America
- University of Arizona Cancer Center, University of Arizona, Tucson, Arizona, United States of America
| | - Steven D. Haenchen
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, United States of America
| | - Kacey C. Ernst
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, United States of America
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111
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Damnjanović K, Graeber J, Ilić S, Lam WY, Lep Ž, Morales S, Pulkkinen T, Vingerhoets L. Parental Decision-Making on Childhood Vaccination. Front Psychol 2018; 9:735. [PMID: 29951010 PMCID: PMC6008886 DOI: 10.3389/fpsyg.2018.00735] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 04/26/2018] [Indexed: 11/13/2022] Open
Abstract
A growing number of parents delay vaccinations or are deciding not to vaccinate their children altogether. This increases the risk of contracting vaccine-preventable diseases and disrupting herd immunity, and also impairs the trust in the capacities of health care systems to protect people. Vaccine hesitancy is related to a range of both psychological and demographic determinants, such as attitudes toward vaccinations, social norms, and trust in science. Our aim is to understand those determinants in parents, because they are a special group in this issue-they act as proxy decision makers for their children, who are unable to decide for themselves. The fact that deciding to vaccinate is a socially forced choice that concerns a child's health makes vaccine-related decisions highly important and involving for parents. This high involvement might lead to parents overemphasizing the potential side effects that they know to be vaccine-related, and by amplifying those, parents are more focused on the potential outcomes of vaccine-related decisions, which can yield specific pattern of the outcome bias. We propose two related studies to investigate factors which promote vaccine hesitancy, protective factors that determine parental vaccination decisions, and outcome bias in parental vaccination intentions. We will explore demographic and psychological factors, and test parental involvement related to vaccine hesitancy using an online battery in a correlation panel design study. The second study is an experimental study, in which we will investigate the moderating role of parents' high involvement in the specific domain of vaccination decision making. We expect that higher involvement among parents, compared to non-parents, will shape the pattern of the proneness to outcome bias. The studies will be conducted across eight countries in Europe and Asia (Finland, Germany, Hong Kong, the Netherlands, Serbia, Slovenia, Spain, and the United Kingdom), rendering findings that will aid with understanding the underlying mechanisms of vaccine hesitancy and paving the way for developing interventions custom-made for parents.
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Affiliation(s)
- Kaja Damnjanović
- Laboratory for Experimental Psychology, Department of Psychology, Faculty of Philosophy, University of Belgrade, Belgrade, Serbia
| | - Johanna Graeber
- Department of Psychology, Faculty of Philosophy, Christian-Albrechts-University Kiel, Kiel, Germany
| | - Sandra Ilić
- Laboratory for Experimental Psychology, Department of Psychology, Faculty of Philosophy, University of Belgrade, Belgrade, Serbia
| | - Wing Y. Lam
- Faculty of Social Sciences, School of Psychology, University of Kent, Canterbury, United Kingdom
| | - Žan Lep
- Department of Psychology, Faculty of Arts, University of Ljubljana, Ljubljana, Slovenia
| | - Sara Morales
- Faculty of Psychology, University of Basque Country, Bilbao, Spain
| | - Tero Pulkkinen
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Loes Vingerhoets
- Department of Psychology, Faculty of Psychology and Neuroscience, University of Maastricht, Maastricht, Netherlands
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Shay LA, Baldwin AS, Betts AC, Marks EG, Higashi RT, Street RL, Persaud D, Tiro JA. Parent-Provider Communication of HPV Vaccine Hesitancy. Pediatrics 2018; 141:peds.2017-2312. [PMID: 29765009 PMCID: PMC6005174 DOI: 10.1542/peds.2017-2312] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2018] [Indexed: 11/24/2022] Open
Abstract
UNLABELLED : media-1vid110.1542/5754332185001PEDS-VA_2017-2312Video Abstract OBJECTIVES: To prevent human papillomavirus (HPV)-related cancers, providers must effectively communicate with HPV vaccine-hesitant parents. Here, we developed a typology characterizing parent-provider communication around HPV vaccine hesitancy. METHODS We audio-recorded 43 visits with unvaccinated adolescents at 6 pediatric clinics in Dallas, Texas in which parents were undecided about HPV vaccination. We qualitatively coded how parents verbally expressed hesitancy (assertive response, asking a question, or expressing concern) and whether providers responded with acquiescence (agree to defer vaccination) and/or persistence (continue discussion). We described the frequency of parent and provider communication codes and same-day vaccination. RESULTS Among the 43 visits, 37 parents expressed hesitancy ≥1 times in many ways. Assertive responses were most common (27 visits), followed by questions (16 visits), and concerns (12 visits). When the first expression of hesitancy was a question or concern, 71% and 75% of adolescents, respectively, received same-day vaccinations, whereas 33% of adolescents who received an initial assertive response were vaccinated. Providers responded with only persistence in 18 visits, a mix of acquiescence and persistence in 13 visits, and only acquiescence in 6 visits. When providers only used persistence, 17 of 18 adolescents were vaccinated; when providers responded with only acquiescence, no adolescents received the vaccine. CONCLUSIONS Our exploratory analysis reveals that providers engaging hesitant parents and addressing their concerns can lead to same-day HPV vaccination. Data reveal that even parents making assertive statements are amenable to influence by providers. Our findings reveal an important missed opportunity when providers simply acquiesce to parental hesitation.
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Affiliation(s)
- Laura A. Shay
- Department of Health Promotion & Behavioral
Sciences, UTHealth School of Public Health in San Antonio, San Antonio,
Texas
| | - Austin S. Baldwin
- Department of Psychology, Southern Methodist
University, Dallas, Texas
| | - Andrea C. Betts
- Department of Clinical Sciences, University of Texas
Southwestern Medical Center, Dallas, Texas;,Department of Health Promotion & Behavioral
Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas
| | - Emily G. Marks
- Department of Clinical Sciences, University of Texas
Southwestern Medical Center, Dallas, Texas
| | - Robin T. Higashi
- Department of Clinical Sciences, University of Texas
Southwestern Medical Center, Dallas, Texas
| | - Richard L. Street
- Department of Communication, Texas Agricultural and
Mechanical University, College Station, Texas;,Department of Medicine, Baylor College of Medicine,
Houston, Texas
| | - Donna Persaud
- Parkland Health and Hospital System, Dallas, Texas;
and
| | - Jasmin A. Tiro
- Department of Clinical Sciences, University of Texas
Southwestern Medical Center, Dallas, Texas;,Harold C. Simmons Comprehensive Cancer Center,
Dallas, Texas
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113
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Brewer NT, Chapman GB, Rothman AJ, Leask J, Kempe A. Increasing Vaccination: Putting Psychological Science Into Action. Psychol Sci Public Interest 2018; 18:149-207. [DOI: 10.1177/1529100618760521] [Citation(s) in RCA: 483] [Impact Index Per Article: 80.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Vaccination is one of the great achievements of the 20th century, yet persistent public-health problems include inadequate, delayed, and unstable vaccination uptake. Psychology offers three general propositions for understanding and intervening to increase uptake where vaccines are available and affordable. The first proposition is that thoughts and feelings can motivate getting vaccinated. Hundreds of studies have shown that risk beliefs and anticipated regret about infectious disease correlate reliably with getting vaccinated; low confidence in vaccine effectiveness and concern about safety correlate reliably with not getting vaccinated. We were surprised to find that few randomized trials have successfully changed what people think and feel about vaccines, and those few that succeeded were minimally effective in increasing uptake. The second proposition is that social processes can motivate getting vaccinated. Substantial research has shown that social norms are associated with vaccination, but few interventions examined whether normative messages increase vaccination uptake. Many experimental studies have relied on hypothetical scenarios to demonstrate that altruism and free riding (i.e., taking advantage of the protection provided by others) can affect intended behavior, but few randomized trials have tested strategies to change social processes to increase vaccination uptake. The third proposition is that interventions can facilitate vaccination directly by leveraging, but not trying to change, what people think and feel. These interventions are by far the most plentiful and effective in the literature. To increase vaccine uptake, these interventions build on existing favorable intentions by facilitating action (through reminders, prompts, and primes) and reducing barriers (through logistics and healthy defaults); these interventions also shape behavior (through incentives, sanctions, and requirements). Although identification of principles for changing thoughts and feelings to motivate vaccination is a work in progress, psychological principles can now inform the design of systems and policies to directly facilitate action.
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Affiliation(s)
- Noel T. Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina
- Lineberger Comprehensive Cancer Center, University of North Carolina
| | | | | | - Julie Leask
- Faculty of Nursing and Midwifery, University of Sydney
- Faculty of Medicine, University of Sydney
| | - Allison Kempe
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine
- Department of Pediatrics, University of Colorado Anschutz Medical Campus
- Department of Pediatrics, Children’s Hospital Colorado, Aurora, Colorado
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114
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Reno JE, O'Leary S, Garrett K, Pyrzanowski J, Lockhart S, Campagna E, Barnard J, Dempsey AF. Improving Provider Communication about HPV Vaccines for Vaccine-Hesitant Parents Through the Use of Motivational Interviewing. JOURNAL OF HEALTH COMMUNICATION 2018; 23:313-320. [PMID: 29474117 DOI: 10.1080/10810730.2018.1442530] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Human papillomavirus (HPV) vaccine uptake is below that of other routine adolescent vaccines. This is due in part to the fact that the HPV vaccine is often not routinely recommended by providers to all eligible adolescents. While providers' recommendations are crucial, even a strongly stated recommendation can be insufficient among HPV vaccine-hesitant parents. Providers must be prepared to respond to parental concerns following giving the recommendation for the HPV vaccine. This paper presents the analysis of implementation of an intervention aimed at improving provider communication with HPV vaccine-hesitant parents. Healthcare providers and staff at eight pediatric and family medicine clinics received communication training that included motivational interviewing (MI) techniques. Process evaluation in the form of serial surveys, as well as program evaluation in the form of focus groups with participating providers and staff, assessed the perceived efficacy of the intervention. Outcomes included time spent discussing the HPV vaccine during clinical visits, providers' self-efficacy for addressing parental HPV vaccine hesitancy, and their general perceptions of the effectiveness of MI techniques. Overall, findings indicate the intervention improved providers' communication with HPV vaccine-hesitant parents and providers reported the use of MI played a central role in improved HPV vaccine acceptance. Lessons learned and recommendations for future interventions are also discussed.
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Affiliation(s)
- Jenna E Reno
- a Adult and Child Consortium for Health Outcomes Research and Delivery Science , University of Colorado Denver , Aurora , USA
| | - Sean O'Leary
- a Adult and Child Consortium for Health Outcomes Research and Delivery Science , University of Colorado Denver , Aurora , USA
| | - Kathleen Garrett
- b Department of Behavioral & Behavioral Health , University of Colorado Denver , USA
| | - Jennifer Pyrzanowski
- a Adult and Child Consortium for Health Outcomes Research and Delivery Science , University of Colorado Denver , Aurora , USA
| | - Steven Lockhart
- a Adult and Child Consortium for Health Outcomes Research and Delivery Science , University of Colorado Denver , Aurora , USA
| | - Elizabeth Campagna
- a Adult and Child Consortium for Health Outcomes Research and Delivery Science , University of Colorado Denver , Aurora , USA
| | - Juliana Barnard
- a Adult and Child Consortium for Health Outcomes Research and Delivery Science , University of Colorado Denver , Aurora , USA
| | - Amanda F Dempsey
- a Adult and Child Consortium for Health Outcomes Research and Delivery Science , University of Colorado Denver , Aurora , USA
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Frew PM, Randall LA, Malik F, Limaye RJ, Wilson A, O'Leary ST, Salmon D, Donnelly M, Ault K, Dudley MZ, Fenimore VL, Omer SB. Clinician perspectives on strategies to improve patient maternal immunization acceptability in obstetrics and gynecology practice settings. Hum Vaccin Immunother 2018; 14:1548-1557. [PMID: 29313458 DOI: 10.1080/21645515.2018.1425116] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Pregnancy is an ideal time to communicate with women about vaccines for themselves and their infants, yet maternal immunization rates remain suboptimal. This study aimed to identify clinic, provider, and staff-related attributes and facilitators to be utilized for a comprehensive vaccine intervention in ob-gyn clinical settings. We conducted in-depth interviews with 24 providers, both healthcare providers (e.g., physicians, nurse practitioners, midwives) and practice managers, from urban and suburban ob-gyn practices in Georgia and Colorado about their immunization attitudes, practices, and patient experiences. Qualitative analyses included Pearson correlation tests to evaluate patterns and relationships within the data to determine themes. Six major themes emerged: 1) strong provider "buy in" for maternal immunization; 2) the supporting role of clinical/interpersonal cues for vaccine promotion; 3) varying provider-patient communication approaches and its influence on maternal and pediatric uptake; 4) an urgent need for a designated office immunization champion; 5) reimbursement and practice implementation challenges; and 6) region differences in attitudes and values toward maternal immunization. Although providers expressed strong support for maternal immunization practices and offered environmental cues for vaccine promotion, practices often lacked a designated, structured role for an immunization champion equipped to manage delicate conversations with patients. The findings reflect needs for immunization champion identification, training, and support, along with best practices guidelines to improve coordination of vaccine promotion and delivery efforts in ob-gyn provider offices. Additionally, provider training on communication approaches to enhance acceptance and uptake of maternal vaccines is warranted.
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Affiliation(s)
- Paula M Frew
- a Emory University School of Medicine , Department of Medicine, Division of Infectious Diseases , Atlanta , GA , USA.,b Emory University Rollins School of Public Health , Hubert Department of Global Health , Atlanta , GA , USA
| | - Laura A Randall
- a Emory University School of Medicine , Department of Medicine, Division of Infectious Diseases , Atlanta , GA , USA
| | - Fauzia Malik
- b Emory University Rollins School of Public Health , Hubert Department of Global Health , Atlanta , GA , USA
| | - Rupali J Limaye
- c Johns Hopkins Bloomberg School of Public Health , Department of International Health, Division of Global Disease Epidemiology and Control , Baltimore , MD , USA
| | - Andrew Wilson
- b Emory University Rollins School of Public Health , Hubert Department of Global Health , Atlanta , GA , USA
| | - Sean T O'Leary
- d University of Colorado Denver , Department of Pediatrics, Division of Infectious Diseases , Denver , CO , USA
| | - Daniel Salmon
- c Johns Hopkins Bloomberg School of Public Health , Department of International Health, Division of Global Disease Epidemiology and Control , Baltimore , MD , USA
| | - Meghan Donnelly
- e University of Colorado School of Medicine , Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine , Denver , CO , USA
| | - Kevin Ault
- f University of Kansas Medical Center , Department of Obstetrics and Gynecology , Kansas City , KS , USA
| | - Matthew Z Dudley
- c Johns Hopkins Bloomberg School of Public Health , Department of International Health, Division of Global Disease Epidemiology and Control , Baltimore , MD , USA
| | - Vincent L Fenimore
- a Emory University School of Medicine , Department of Medicine, Division of Infectious Diseases , Atlanta , GA , USA
| | - Saad B Omer
- b Emory University Rollins School of Public Health , Hubert Department of Global Health , Atlanta , GA , USA.,g Emory University Rollins School of Public Health , Department of Epidemiology , Atlanta , GA , USA.,h Emory University School of Medicine , Department of Medicine, Division of Pediatrics , Atlanta , GA , USA
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116
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Shapiro GK, Tatar O, Dube E, Amsel R, Knauper B, Naz A, Perez S, Rosberger Z. The vaccine hesitancy scale: Psychometric properties and validation. Vaccine 2017; 36:660-667. [PMID: 29289384 DOI: 10.1016/j.vaccine.2017.12.043] [Citation(s) in RCA: 245] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 12/05/2017] [Accepted: 12/14/2017] [Indexed: 12/31/2022]
Abstract
INTRODUCTION The SAGE Working Group on Vaccine Hesitancy developed a vaccine hesitancy measure, the Vaccine Hesitancy Scale (VHS). This scale has the potential to aid in the advancement of research and immunization policy but has not yet been psychometrically evaluated. METHODS Using a cross-sectional design, we collected self-reported survey data from a large national sample of Canadian parents from August to September 2016. An online questionnaire was completed in English or French. We used exploratory and confirmatory factor analysis to identify latent constructs underlying parents' responses to 10 VHS items (response scale 1-5, with higher scores indicating greater hesitancy). In addition to the VHS, measures included socio-demographics items, vaccine attitudes, parents' human papillomavirus (HPV) vaccine decision-making stage, and vaccine refusal. RESULTS A total of 3779 Canadian parents completed the survey in English (74.1%) or French (25.9%). Exploratory and confirmatory factor analysis revealed a two-factor structure best explained the data, consisting of 'lack of confidence' (M = 1.98, SD = 0.72) and 'risks' (M = 3.07, SD = 0.95). Significant Pearson correlations were found between the scales and related vaccine attitudes. ANOVA analyses found significant differences in the VHS sub-scales by parents' vaccine decision-making stages (p < .001). Independent samples t-tests found that the VHS sub-scales were associated with HPV vaccine refusal and refusing another vaccine (p < .001). Socio-demographic differences in the VHS were found; however, effect sizes were small (η2 < 0.02). CONCLUSIONS The VHS was found to have two factors that have construct and criterion validity in identifying vaccine hesitant parents. A limitation of the VHS was few items that loaded on the 'risks' component and a lack of positively and negatively worded items for both components. Based on these results, we suggest modifying the wording of some items and adding items on risk perceptions.
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Affiliation(s)
- Gilla K Shapiro
- Department of Psychology, McGill University, 2001 McGill College Avenue, Montreal, Québec, Canada; Lady Davis Institute for Medical Research, Jewish General Hospital, 4333 Côte St-Catherine Road, Montreal, Québec, Canada.
| | - Ovidiu Tatar
- Lady Davis Institute for Medical Research, Jewish General Hospital, 4333 Côte St-Catherine Road, Montreal, Québec, Canada
| | - Eve Dube
- Institut National de Santé Publique du Québec, Québec, Canada
| | - Rhonda Amsel
- Department of Psychology, McGill University, 2001 McGill College Avenue, Montreal, Québec, Canada
| | - Barbel Knauper
- Department of Psychology, McGill University, 2001 McGill College Avenue, Montreal, Québec, Canada
| | - Anila Naz
- Lady Davis Institute for Medical Research, Jewish General Hospital, 4333 Côte St-Catherine Road, Montreal, Québec, Canada
| | - Samara Perez
- Department of Psychology, McGill University, 2001 McGill College Avenue, Montreal, Québec, Canada; Lady Davis Institute for Medical Research, Jewish General Hospital, 4333 Côte St-Catherine Road, Montreal, Québec, Canada
| | - Zeev Rosberger
- Department of Psychology, McGill University, 2001 McGill College Avenue, Montreal, Québec, Canada; Lady Davis Institute for Medical Research, Jewish General Hospital, 4333 Côte St-Catherine Road, Montreal, Québec, Canada; Louise Granofsky Psychosocial Oncology Program, Jewish General Hospital, 4333 Côte St-Catherine Road, Montreal, Québec, Canada; Departments of Psychiatry and Oncology, McGill University, 1205 Dr. Penfield Avenue, Montreal, Québec, Canada
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117
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Olszewska M, Smykla B, Gdańska M, Kiełbasa G, Ficinski M, Szymońska I, Starzec K, Kwinta P. The analysis of parental attitude towards active immunoprophylaxis and its influence on the implementation of an Immunization Schedule among children in Poland. CHILDRENS HEALTH CARE 2017. [DOI: 10.1080/02739615.2017.1354293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Marta Olszewska
- Students’ Scientific Group at Chair of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Barbara Smykla
- Students’ Scientific Group at Chair of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Marta Gdańska
- Students’ Scientific Group at Chair of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Grzegorz Kiełbasa
- Students’ Scientific Group at Chair of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Matthew Ficinski
- Students’ Scientific Group at Chair of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Izabela Szymońska
- Chair of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Katarzyna Starzec
- Chair of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Przemko Kwinta
- Chair of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
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118
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Shapiro GK, Perez S, Naz A, Tatar O, Guichon JR, Amsel R, Zimet GD, Rosberger Z. Investigating Canadian parents' HPV vaccine knowledge, attitudes and behaviour: a study protocol for a longitudinal national online survey. BMJ Open 2017; 7:e017814. [PMID: 29025844 PMCID: PMC5652458 DOI: 10.1136/bmjopen-2017-017814] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 07/27/2017] [Accepted: 08/01/2017] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Human papillomavirus (HPV), a sexually transmitted infection, can cause anogenital warts and a number of cancers. To prevent morbidity and mortality, three vaccines have been licensed and are recommended by Canada's National Advisory Committee on Immunisation (for girls since 2007 and boys since 2012). Nevertheless, HPV vaccine coverage in Canada remains suboptimal in many regions. This study will be the first to concurrently examine the correlates of HPV vaccine decision-making in parents of school-aged girls and boys and evaluate changes in parental knowledge, attitudes and behaviours over time. METHODS AND ANALYSIS Using a national, online survey utilising theoretically driven constructs and validated measures, this study will identify HPV vaccine coverage rates and correlates of vaccine decision-making in Canada at two time points (August-September 2016 and June-July 2017). 4606 participants will be recruited to participate in an online survey through a market research and polling firm using email invitations. Data cleaning methods will identify inattentive or unmotivated participants. ETHICS AND DISSEMINATION The study received research ethics board approval from the Research Review Office, Integrated Health and Social Services University Network for West-Central Montreal (CODIM-FLP-16-219). The study will adopt a multimodal approach to disseminate the study's findings to researchers, clinicians, cancer and immunisation organisations and the public in Canada and internationally.
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Affiliation(s)
- Gilla K Shapiro
- Department of Psychology, McGill University, Montreal, Quebec, Canada
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada
| | - Samara Perez
- Department of Psychology, McGill University, Montreal, Quebec, Canada
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada
| | - Anila Naz
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada
| | - Ovidiu Tatar
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada
| | - Juliet R Guichon
- Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rhonda Amsel
- Department of Psychology, McGill University, Montreal, Quebec, Canada
| | - Gregory D Zimet
- Section of Adolescent Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Zeev Rosberger
- Department of Psychology, McGill University, Montreal, Quebec, Canada
- Department of Oncology, McGill University, Montreal, Quebec, Canada
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada
- Louise Granofsky Psychosocial Oncology Program, Segal Cancer Center, Jewish General Hospital, Montreal, Quebec, Canada
- Department of Psychiatry, McGill University, Montreal, Quebec, Canada
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119
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Bocquier A, Ward J, Raude J, Peretti-Watel P, Verger P. Socioeconomic differences in childhood vaccination in developed countries: a systematic review of quantitative studies. Expert Rev Vaccines 2017; 16:1107-1118. [PMID: 28914112 DOI: 10.1080/14760584.2017.1381020] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The reasons for vaccine hesitancy and its relation to individual socioeconomic status (SES) must be better understood. Areas covered: This review focused on developed countries with programs addressing major financial barriers to vaccination access. We systematically reviewed differences by SES in uptake of publicly funded childhood vaccines and in cognitive determinants (beliefs, attitudes) of parental decisions about vaccinating their children. Using the PRISMA statement to guide this review, we searched three electronic databases from January 2000 through April 2016. We retained 43 articles; 34 analyzed SES differences in childhood vaccine uptake, 7 examined differences in its cognitive determinants, and 2 both outcomes. Expert commentary: Results suggest that barriers to vaccination access persist among low-SES children in several settings. Vaccination programs could be improved to provide all mandatory and recommended vaccines 100% free of charge, in both public organizations and private practices, and to reimburse vaccine administration. Multicomponent interventions adapted to the context could also be effective in reducing these inequalities. For specific vaccines (notably for measles, mumps, and rubella), in UK and Germany, uptake was lowest among the most affluent. Interventions carefully tailored to respond to specific concerns of vaccine-hesitant parents, without reinforcing hesitancy, are needed.
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Affiliation(s)
- Aurélie Bocquier
- a Aix Marseille Univ, INSERM, IRD, SESSTIM, Economics and Social Sciences Applied to Health & Analysis of Medical Information , Marseille , France.,b ORS PACA, Southeastern Health Regional Observatory , Marseille , France
| | - Jeremy Ward
- a Aix Marseille Univ, INSERM, IRD, SESSTIM, Economics and Social Sciences Applied to Health & Analysis of Medical Information , Marseille , France.,c UMR 8236 (LIED) , Université Paris Diderot , Paris , France
| | - Jocelyn Raude
- d UMR "Emergence des Pathologies Virales" (EPV: Aix-Marseille University - IRD 190 - Inserm 1207 - EHESP) , Marseille , France.,e UMR PIMIT, INSERM 1187, CNRS 9192, IRD 249. Plateforme Technologique CYROI , Université de La Réunion , Réunion , France
| | - Patrick Peretti-Watel
- a Aix Marseille Univ, INSERM, IRD, SESSTIM, Economics and Social Sciences Applied to Health & Analysis of Medical Information , Marseille , France.,b ORS PACA, Southeastern Health Regional Observatory , Marseille , France
| | - Pierre Verger
- a Aix Marseille Univ, INSERM, IRD, SESSTIM, Economics and Social Sciences Applied to Health & Analysis of Medical Information , Marseille , France.,b ORS PACA, Southeastern Health Regional Observatory , Marseille , France
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120
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Kurosky SK, Davis KL, Krishnarajah G. Effect of combination vaccines on completion and compliance of childhood vaccinations in the United States. Hum Vaccin Immunother 2017; 13:2494-2502. [PMID: 28881166 PMCID: PMC5703402 DOI: 10.1080/21645515.2017.1362515] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Vaccination at age-appropriate intervals increases protection against morbidity and mortality; however, compliance rates among children remain low partly due to a complicated vaccination schedule. Use of combination vaccines reduces the number of injections per visit; however, there is limited evidence quantifying the effect of combination vaccines on vaccination rates. To examine how combination vaccines impact childhood completion (receipt of recommended doses) and compliance (receipt of age-appropriate vaccinations) rates, this study analyzed vaccination data from the 2012 National Immunization Survey (NIS), a nationally representative cross-sectional survey of caregivers of children aged 24 to 35 months in the United States. Vaccines were categorized as combination or single antigen. Vaccine completion was measured at ages 8, 18, and 24 months. Vaccine compliance and time undervaccinated were measured at 24 months. Children who received at least 1 combination vaccine (86%) had a higher completion rate (69%) and compliance with the full vaccine series (4:3:1:3:3:1:4 series) at 24 months (24%) than those who received only single-antigen vaccines (50% and 13%, respectively). Receipt of combination vaccine was associated with an increased likelihood of completing all recommended vaccinations at 24 months (odds ratio [OR] = 2.5; P < 0.001), receiving all vaccinations at age-appropriate times (OR = 2.2; P < 0.001), and less than 7 months undervaccinated (OR = 2.4; P < 0.001). Combination vaccines were associated with improved completion and compliance and should be encouraged among children who are undervaccinated or who received single-antigen vaccines only.
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Affiliation(s)
| | - Keith L Davis
- a RTI Health Solutions , Research Triangle Park, NC , USA
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121
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Attwell K, Smith DT. Parenting as politics: social identity theory and vaccine hesitant communities. INTERNATIONAL JOURNAL OF HEALTH GOVERNANCE 2017. [DOI: 10.1108/ijhg-03-2017-0008] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The purpose of this paper is to develop a theoretical framework for understanding the identity politics associated with parental hesitancy and refusal of vaccines for their children (“vaccine hesitancy or refusal” or “VHR”). Understanding these identity politics helps policymakers to craft appropriate communication interventions that do not make the problem worse.
Design/methodology/approach
Social identity theory is a way of understanding how group identities develop around the lifestyle practices that often include refusal to vaccinate, and how this group identity is accentuated by conflict with the pro-vaccinating societal mainstream. This paper critically appraises existing studies of VHR to explore this groupness across many different contexts.
Findings
Groupness is evident across many different contexts. There are also key group characteristics: preference for natural birth and breastfeeding, nature as a concept and use of complementary and alternative medicine.
Research limitations/implications
The paper is speculative and theoretical, using existing sources. Future studies will need to demonstrate empirically with new data. However, this theoretical approach sets up a new research agenda.
Social implications
These findings can help governments and policymakers minimise social conflict that risks further polarising vaccine conversations and wedging parents on the fence.
Originality/value
This paper argues that the decision to vaccinate or not is an inherently social one, not a matter of pure individual rationality. This is a novel approach to engaging with what is often characterised and studied as an individual decision.
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122
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Smith TC. Vaccine Rejection and Hesitancy: A Review and Call to Action. Open Forum Infect Dis 2017; 4:ofx146. [PMID: 28948177 PMCID: PMC5597904 DOI: 10.1093/ofid/ofx146] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 07/11/2017] [Indexed: 01/20/2023] Open
Abstract
Vaccine refusal has been a recurring story in the media for well over a decade. Although there is scant evidence that refusal is genuinely increasing in the population, multiple studies have demonstrated concerning patterns of decline of confidence in vaccines, the medical professionals who administer vaccines, and the scientists who study and develop vaccines. As specialists in microbiology, immunology, and infectious diseases, scientists are content experts but often lack the direct contact with individuals considering vaccination for themselves or their children that healthcare professionals have daily. This review examines the arguments and players in the US antivaccination scene, and it discusses ways that experts in infectious diseases can become more active in promoting vaccination to friends, family, and the public at large.
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Affiliation(s)
- Tara C Smith
- College of Public Health, Kent State University, Ohio
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123
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Abstract
Aim To review the available literature pertaining to fatalities following vaccine administration and, in particular, cases of vaccine-related fatal anaphylaxis. Method The MEDLINE database was systematically searched up to March 2016 to identify all relevant articles pertaining to fatal cases of anaphylaxis following vaccine administration. Results Six papers pertaining to fatal anaphylaxis following vaccination were found relevant. Mast cell tryptase and total IgE concentration was assessed exclusively in one case. Laryngeal edema was not detected in any of these cases, whereas eosinophil or mast cell infiltration was observed in lymphoid organs. In one case, immunohistochemical investigations using anti-tryptase antibodies allowed pulmonary mast cells and degranulating mast cells with tryptase-positive material outside to be identified. Conclusion In any suspected IgE-mediated fatal anaphylactic cases, biochemical investigations should be systematically performed for forensic purposes. Splenic tissue should be routinely sampled for immunohistochemical investigations in all suspected anaphylaxis-related deaths and mast cell/eosinophil infiltrations should be systematically sought out in the spleen, myocardium, and coronary artery wall. The hypothesis of fatal anaphylaxis following vaccination should be formulated exclusively when circumstantial data, available medical records, laboratory investigations, and autopsy or histology findings converge in a consistent pattern. The reasonable exclusion of alternative causes of death after all postmortem investigations is also imperative in order to establish or rule out a cause-and-effect relationship between vaccine administration and any presumptive temporarily-related death.
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Affiliation(s)
- Cristian Palmiere
- Cristian Palmiere, CURML, Chemin de la Vulliette 4, 1000 Lausanne 25, Switzerland,
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Carpiano RM, Fitz NS. Public attitudes toward child undervaccination: A randomized experiment on evaluations, stigmatizing orientations, and support for policies. Soc Sci Med 2017; 185:127-136. [PMID: 28578210 DOI: 10.1016/j.socscimed.2017.05.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 05/02/2017] [Accepted: 05/05/2017] [Indexed: 10/19/2022]
Abstract
Child undervaccination is a complex public health problem and a contentious social and political issue. Efforts to increase vaccination coverage require understanding how the public evaluates different reasons for child undervaccination, which may influence attitudes, stigmatizing behaviors, and support for vaccination policies. We conducted a vignette experiment with a United States national online sample (n = 1469) to investigate how and why different undervaccination actions shape evaluations (blame, anger, sympathy, differentness, credibility, dangerousness), stigmatizing orientations (social distance, discrimination), and support for particular policies (e.g., research funding, belief exemptions, fines). Each participant was randomly assigned to read one of four vignettes that described a mother who either refused vaccines, delayed vaccines, encountered social barriers to obtaining vaccines, or was up-to-date on vaccines for her child. Compared to the up-to-date condition, each undervaccination action predicted significantly more negative evaluations and stigmatizing orientations. Vaccine refusal was the most negatively appraised. Differences in social distance and discrimination were explained by negative evaluations about the parent. These evaluations and orientations predicted support for a range of policies. Negative parental evaluations were associated with increased support for more severe policies. We discuss the implications of these findings for addressing undervaccination and informing health scholarship on stigma.
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Affiliation(s)
| | - Nicholas S Fitz
- National Core for Neuroethics, University of British Columbia, Canada
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125
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Robison SG, Osborn AW. The Concordance of Parent and Child Immunization. Pediatrics 2017; 139:peds.2016-2883. [PMID: 28557731 DOI: 10.1542/peds.2016-2883] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND A substantial body of work has related survey-based parental vaccine hesitancy to noncompliant childhood immunization. However little attention has been paid to the connection between parents' own immunization behavior and the immunizations their children receive. METHODS Using the Oregon ALERT Immunization Information System, we identified adult caregiver-child pairs for children between 9 months and 17 years of age. The likelihood of adult-child concordance of influenza immunization per influenza season from 2010-2011 through 2014-2015 was assessed. The utility of adult immunization as a predictor was also assessed for other, noninfluenza recommended immunizations for children and adolescents. RESULTS A total of 450 687 matched adult caregiver-child pairs were included in the study. The children of immunizing adults were 2.77 times more likely to also be immunized for seasonal influenza across all seasons (95% confidence interval, 2.74-2.79), with similar results applying within each season. Adult immunization status was also significantly associated with the likelihood of children and adolescents getting other noninfluenza immunizations, such as the human papillomavirus vaccine (HPV). When adults improved their own behavior from nonimmunizing to immunizing across influenza seasons, their children if not immunized in the previous season were 5.44 times (95% confidence interval, 5.35-5.53) more likely to become immunized for influenza. CONCLUSIONS Children's likelihood of following immunization recommendations is associated with the immunization behavior of their parents. Encouraging parental immunization is a potential tool for increasing children's immunization rates.
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Affiliation(s)
- Steve G Robison
- Oregon Immunization Program, Oregon Health Division, Portland, Oregon
| | - Andrew W Osborn
- Oregon Immunization Program, Oregon Health Division, Portland, Oregon
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126
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Gesser-Edelsburg A, Walter N, Shir-Raz Y, Sassoni Bar-Lev O, Rosenblat S. The behind-the-scenes activity of parental decision-making discourse regarding childhood vaccination. Am J Infect Control 2017; 45:267-271. [PMID: 27856072 DOI: 10.1016/j.ajic.2016.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 10/13/2016] [Accepted: 10/13/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Vaccine compliance has long been a cause for concern for health authorities throughout the world. However very little effort has been made to examine parental discourse during the decision-making process. METHODS An online survey was conducted (N = 437) to examine predictors of parents' attitudes regarding childhood vaccination. RESULTS Hesitant parents were 4 times more likely to conduct intrafamily discussion regarding vaccination compared with provaccination parents (Exp[B] = 4.26). There were no significant differences between hesitant and antivaccination parents with respect to intrafamily discussion. Hesitant parents were also 4 times more likely than provaccination parents to report intrafamily disagreements regarding vaccination (Exp[B] = 4.27). They were also twice as likely as antivaccination parents to express disagreements regarding vaccination within their families (Exp[B] = 2.33). Likewise, Jewish parents were significantly more likely to define themselves as vaccination-hesitant, whereas Muslim parents were significantly more likely to be provaccination. CONCLUSIONS To improve the way health organizations communicate information about vaccines and increase parental trust in immunization programs, we should not only look at the level of understanding, perceptions, and biases of different groups, but also thoroughly examine parents' decision-making processes and the discourse during this process. We must communicate risk to all groups, including the provaccination group, to improve parents' decision making and the process of informed consent.
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127
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Corben P, Leask J. To close the childhood immunization gap, we need a richer understanding of parents' decision-making. Hum Vaccin Immunother 2016; 12:3168-3176. [PMID: 27564975 PMCID: PMC5215493 DOI: 10.1080/21645515.2016.1221553] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 07/22/2016] [Accepted: 08/03/2016] [Indexed: 12/22/2022] Open
Abstract
Vaccination is widely acknowledged as one of the most successful public health interventions globally and in most high-income countries childhood vaccination coverage rates are moderately high. Yet in many instances, immunisation rates remain below aspirational targets and have shown only modest progress toward those targets in recent years, despite concerted efforts to improve uptake. In part, coverage rates reflect individual parents' vaccination attitudes and decisions and, because vaccination decision-making is complex and context-specific, it remains challenging at individual and community levels to assist parents to make positive decisions. Consequently, in the search for opportunities to improve immunisation coverage, there has been a renewed research focus on parents' decision-making. This review provides an overview of the literature surrounding parents' vaccination decision-making, offering suggestions for where efforts to increase vaccination coverage should be targeted and identifying areas for further research.
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Affiliation(s)
- Paul Corben
- North Coast Public Health, Mid North Coast Local Health District, Port Macquarie, New South Wales, Australia
| | - Julie Leask
- School of Public Health, University of Sydney, University of Sydney, NSW, Australia
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128
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Repalust A, Šević S, Rihtar S, Štulhofer A. Childhood vaccine refusal and hesitancy intentions in Croatia: insights from a population-based study. PSYCHOL HEALTH MED 2016; 22:1045-1055. [PMID: 27899030 DOI: 10.1080/13548506.2016.1263756] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Considering that programmatic data suggest a recent rise in vaccine refusal in Croatia, this study, first of its kind in Southeast Europe, aimed to estimate the prevalence, and sociodemographic, and sociocultural determinants of childhood vaccine refusal and hesitancy (CVRH) intentions among Croatian adults. Multi-stage stratified population-based survey included 1000 individuals aged 18-88 years (Mage = 47.7, SD = 17.8), of whom 51.7% were women. The outcome, a categorical indicator, distinguished among individuals who would approve vaccinating their children (vaccine accepting), those who would approve some but not all vaccines (vaccine hesitant), and those who would refuse vaccination (vaccine refusing). A sizeable minority of participants was characterized by childhood vaccine refusal (10.6%) and hesitancy intentions (19.5%). In a multivariate assessment controlling for parenthood, the odds of vaccine hesitancy were significantly increased by a younger age (AOR = 1.96-3.03, p < .01). Religiosity (AOR = 1.12, p < .05) and the use of alternative medicine (AOR = 2.85, p < .001) increased the odds of vaccine refusal. However, individual characteristics seem to be relatively poor predictors of CVRH intentions in Croatia. Following the social contagion model, future research should move beyond individual-level approach and take into account social interaction and social network effects.
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Affiliation(s)
- Anja Repalust
- a Department of Sociology, Faculty of Humanities and Social Sciences , University of Zagreb , Zagreb , Croatia
| | - Sandra Šević
- a Department of Sociology, Faculty of Humanities and Social Sciences , University of Zagreb , Zagreb , Croatia
| | - Stanko Rihtar
- b Institute of Social Sciences I. Pilar , Zagreb , Croatia
| | - Aleksandar Štulhofer
- a Department of Sociology, Faculty of Humanities and Social Sciences , University of Zagreb , Zagreb , Croatia
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129
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Changes in childhood immunization decisions in the United States: Results from 2012 & 2014 National Parental Surveys. Vaccine 2016; 34:5689-5696. [PMID: 27720447 DOI: 10.1016/j.vaccine.2016.08.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 07/30/2016] [Accepted: 08/01/2016] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Understanding the current status of parents' vaccine decision making is crucial to inform public policy. We sought to assess changes in vaccine decisions among parents of young children. METHODS We conducted a web-based national poll of parents of children <7years in 2012 and 2014. Participants reported vaccine decisions for their youngest child. We calculated survey-weighted population estimates of overall immunizations decisions, and delay/refusal rates for specific vaccines. RESULTS In 2012, 89.2% (95% CI, 87.3-90.8%) reported accepting or planning to accept all recommended non-influenza childhood vaccines, 5.5% (4.5-6.6%) reported intentionally delaying one or more, and 5.4% (4.1-6.9%) reported refusing one or more vaccines. In 2014, the acceptance, delay, and refusal rates were 90.8% (89.3-92.1%), 5.6% (4.6-6.9%), and 3.6% (2.8-4.5%), respectively. Between 2012 and 2014, intentional vaccine refusal decreased slightly among parents of older children (2-6years) but not younger children (0-1years). The proportion of parents working to catch up on all vaccines increased while those refusing some but not all vaccines decreased. The South experienced a significant increase in estimated acceptance (90.1-94.1%) and a significant decrease in intentional ongoing refusal (5.0-2.1%). Vaccine delay increased in the Northeast (3.2-8.8%). CONCLUSIONS Nationally, acceptance and ongoing intentional delay of recommended non-influenza childhood vaccines were stable. These findings suggest that more effort is warranted to counter persistent vaccine hesitancy, particularly at the local level. Longitudinal monitoring of immunization attitudes is also warranted to evaluate temporal shifts over time and geographically.
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130
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Nowak GJ, Cacciatore MA. Parents' confidence in recommended childhood vaccinations: Extending the assessment, expanding the context. Hum Vaccin Immunother 2016; 13:687-700. [PMID: 27682979 DOI: 10.1080/21645515.2016.1236881] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
There has been significant and growing interest in vaccine hesitancy and confidence in the United States as well as across the globe. While studies have used confidence measures, few studies have provided in-depth assessments and no studies have assessed parents' confidence in vaccines in relationship to other frequently recommended health-related products for young children. This study used a nationally representative sample of 1000 US parents to identify confidence levels for recommended vaccinations, antibiotics, over-the-counter (OTC) medicines, and vitamins for children. The analyses examined associations between confidence ratings, vaccination behaviors and intentions, and trust in healthcare provider, along with associations between confidence ratings and use of the other health-related products. Parents' confidence in vaccines was relatively high and high relative to antibiotics, OTC medicines and vitamins. For all 4 health-related products examined, past product experience and knowledge of bad or adverse outcomes negatively impacted parents' confidence levels. Confidence levels were associated with both trust in advice from their child's healthcare provider and acceptance of healthcare provider recommendations. Parents in some groups, such as those with lower income and education levels, were more likely to have less confidence not just in vaccines, but also in antibiotics and OTC medicines for children. Overall, the findings extend understanding of vaccine confidence, including by placing it into a broader context.
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Affiliation(s)
- Glen J Nowak
- a Grady College Center for Health & Risk Communication, Grady College of Journalism and Mass Communication, University of Georgia , Athens , GA , USA
| | - Michael A Cacciatore
- b Grady College of Journalism and Mass Communication, University of Georgia , Athens , GA , USA
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131
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Abstract
Vaccines are some of if not the most successful public health endeavors ever put into practice. Countless lives have been saved and the occurrences of vaccine preventable diseases are at a fraction of the rate experienced before vaccines. Vaccines and the realization of their compulsory scheduling are highly studied, safe, and purposeful. Despite these realities, there are an alarming number of parents who do not permit the vaccination of their children as scheduled. This is known in the health community as vaccine hesitancy and commonly portrayed in popular media as anti-vaccination sediment. This analysis opens with the topic as it was addressed during a September 2015 debate for the Republic Party's 2016 presidential nomination. Some key historical aspects of vaccine hesitancy are presented. This history leads to a description of the 2014-2015 measles outbreak in California. The factors that aide in the recruitment of under vaccination are then explored. Finally, select strategies to control, combat, and potentially attenuate vaccine hesitancy are presented.
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Affiliation(s)
- David Callender
- a School of Public Health and Health Sciences, University of Massachusetts Amherst , Amherst , MA , USA
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132
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Comparative analysis of the Parent Attitudes about Childhood Vaccines (PACV) short scale and the five categories of vaccine acceptance identified by Gust et al. Vaccine 2016; 34:4964-4968. [PMID: 27566902 DOI: 10.1016/j.vaccine.2016.08.046] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 07/27/2016] [Accepted: 08/12/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND There is a need to develop a standardized tool to aid in identifying, measuring and classifying the unique needs of vaccine-hesitant parents (VHPs). This will also assist in designing tailored interventions to address these needs. The Parental Attitude about Childhood Vaccines (PACV) short scale developed by Opel et al., and the Gust et al. vaccine acceptance categories have been acknowledged as potentially useful tools to measure parental vaccine hesitancy. The PACV short scale requires further validation. In our study, we evaluated how the Gust et al. vaccine acceptance categories correspond with the PACV short scale. METHODS As part of a larger study on vaccine attitudes, using the PACV short scale and Gust et al. vaccine acceptance categories, we assessed the correlation between the two measures using Spearman correlation coefficient, and the association between the two measures using the Cochran-Mantel-Haentszel test of association. We used logistic regression modelling to compare the association between a child's up-to-date immunization status and (a) PACV short scale and (b) Gust et al. vaccine acceptance categories. RESULTS The PACV short scale and Gust et al. vaccine acceptance categories were positively correlated (r=0.6, df=198, p<0.05), and the Cochran-Mantel-Haentszel test of association yielded a statistically significant association (p<0.05). The two scales similarly predicted children's up-to-date immunization status for all recommended childhood vaccines. CONCLUSION The ability of the PACV short scale to identify and classify parental vaccine hesitancy is similar to classification using Gust et al. vaccine acceptance categories, and both measure linear entities. The PACV short scale is recommended for screening parents at their first pediatric visit because it is easier to administer. A clearer understanding of how to classify parental vaccine hesitancy can be used to design tailored interventions based on these classifications, to address their specific needs.
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133
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Lakhan N, Clarke M, Mathew SM, Marshall H. Retrospective review of factors associated with severe hospitalised community-acquired influenza in a tertiary paediatric hospital in South Australia. Influenza Other Respir Viruses 2016; 10:479-485. [PMID: 27381474 PMCID: PMC5059954 DOI: 10.1111/irv.12403] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2016] [Indexed: 11/29/2022] Open
Abstract
Background Influenza infection can result in severe disease with debilitating complications. Young children have the highest rate of influenza hospitalisations with various factors influencing influenza susceptibility and severity. Objectives This study aimed to determine the disease burden and assess risk factors for severe hospitalised influenza in South Australian children under 5 years of age. Methods Influenza admissions to the tertiary paediatric hospital in South Australia from 2008 to 2012 were identified. Data from laboratory‐confirmed influenza cases were collected, including infecting influenza strain, co‐infections, prematurity, pre‐existing medical comorbidities and other potential risk factors. Predictors of high‐level care were assessed using logistic regression. Results A total of 267 children with laboratory‐confirmed influenza were hospitalised. Of these, 147 admissions (53%) occurred in children without underlying medical risk factors. Eighteen children (7%) required high‐level care, of which 11 (61%) had no underlying medical risk factors. No deaths were reported. The majority of children were unimmunised against influenza. Co‐infections were identified in 40% of children (n = 107). Influenza B was associated with a requirement for higher care (OR 3.7, CI 1.3–10.9, P = .02) as was a history of food allergies (OR 9.7, CI 1.5–61.4, P = .02) and iron deficiency anaemia (OR 4.8, CI 1.4–16.1, P = .01). Conclusions Influenza can be a severe illness, even in children without underlying medical conditions. The identification of Influenza B strain, history of food allergies and iron deficiency anaemia as predictors of severity in hospitalised cases warrants further investigation and may have important implications for preventative strategies to reduce the burden of childhood influenza.
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Affiliation(s)
- Nerissa Lakhan
- Vaccinology and Immunology Research Trials Unit, Women's and Children's Hospital, Adelaide, SA, Australia.,School of Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Michelle Clarke
- Vaccinology and Immunology Research Trials Unit, Women's and Children's Hospital, Adelaide, SA, Australia.,School of Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Suja M Mathew
- Vaccinology and Immunology Research Trials Unit, Women's and Children's Hospital, Adelaide, SA, Australia.,Flinders University and Flinders Medical Centre, Adelaide, SA, Australia
| | - Helen Marshall
- Vaccinology and Immunology Research Trials Unit, Women's and Children's Hospital, Adelaide, SA, Australia. .,School of Medicine, University of Adelaide, Adelaide, SA, Australia. .,School of Public Health, University of Adelaide, Adelaide, SA, Australia. .,Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia.
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134
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Ludolph R, Allam A, Schulz PJ. Manipulating Google's Knowledge Graph Box to Counter Biased Information Processing During an Online Search on Vaccination: Application of a Technological Debiasing Strategy. J Med Internet Res 2016; 18:e137. [PMID: 27255736 PMCID: PMC4911515 DOI: 10.2196/jmir.5430] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 02/17/2016] [Accepted: 03/21/2016] [Indexed: 11/13/2022] Open
Abstract
Background One of people’s major motives for going online is the search for health-related information. Most consumers start their search with a general search engine but are unaware of the fact that its sorting and ranking criteria do not mirror information quality. This misconception can lead to distorted search outcomes, especially when the information processing is characterized by heuristic principles and resulting cognitive biases instead of a systematic elaboration. As vaccination opponents are vocal on the Web, the chance of encountering their non‒evidence-based views on immunization is high. Therefore, biased information processing in this context can cause subsequent impaired judgment and decision making. A technological debiasing strategy could counter this by changing people’s search environment. Objective This study aims at testing a technological debiasing strategy to reduce the negative effects of biased information processing when using a general search engine on people’s vaccination-related knowledge and attitudes. This strategy is to manipulate the content of Google’s knowledge graph box, which is integrated in the search interface and provides basic information about the search topic. Methods A full 3x2 factorial, posttest-only design was employed with availability of basic factual information (comprehensible vs hardly comprehensible vs not present) as the first factor and a warning message as the second factor of experimental manipulation. Outcome variables were the evaluation of the knowledge graph box, vaccination-related knowledge, as well as beliefs and attitudes toward vaccination, as represented by three latent variables emerged from an exploratory factor analysis. Results Two-way analysis of variance revealed a significant main effect of availability of basic information in the knowledge graph box on participants’ vaccination knowledge scores (F2,273=4.86, P=.01), skepticism/fear of vaccination side effects (F2,273=3.5, P=.03), and perceived information quality (F2,273=3.73, P=.02). More specifically, respondents receiving comprehensible information appeared to be more knowledgeable, less skeptical of vaccination, and more critical of information quality compared to participants exposed to hardly comprehensible information. Although, there was no significant interaction effect between the availability of information and the presence of the warning, there was a dominant pattern in which the presence of the warning appeared to have a positive influence on the group receiving comprehensible information while the opposite was true for the groups exposed to hardly comprehensible information and no information at all. Participants evaluated the knowledge graph box as moderately to highly useful, with no significant differences among the experimental groups. Conclusion Overall, the results suggest that comprehensible information in the knowledge graph box positively affects participants’ vaccination-related knowledge and attitudes. A small change in the content retrieval procedure currently used by Google could already make a valuable difference in the pursuit of an unbiased online information search. Further research is needed to gain insights into the knowledge graph box’s entire potential.
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Affiliation(s)
- Ramona Ludolph
- Institute of Communication and Health, Faculty of Communication Sciences, University of Lugano (Università della Svizzera italiana), Lugano, Switzerland.
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135
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Visser O, Hautvast JLA, van der Velden K, Hulscher MEJL. Intention to Accept Pertussis Vaccination for Cocooning: A Qualitative Study of the Determinants. PLoS One 2016; 11:e0155861. [PMID: 27253386 PMCID: PMC4890858 DOI: 10.1371/journal.pone.0155861] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 05/05/2016] [Indexed: 12/21/2022] Open
Abstract
Context Several countries have reported a resurgence of pertussis in the last decades. This puts infants (especially <6 months) at risk of severe complications, because they are too young to be fully protected by vaccination. The global pertussis initiative has proposed pertussis vaccination of young infants’ close contacts, in order to reduce pertussis transmission and the burden of the disease on infants. Our aim is to explore the perceived determinants (barriers and facilitators) of intention to accept vaccination among the possible target groups of pertussis vaccination for cocooning. Consideration of these determinants is necessary to optimise the uptake of the vaccination. Methods We conducted 13 focus groups and six individual semi-structured interviews with members of possible target groups for pertussis cocooning (i.e. parents, maternity assistants, midwives, and paediatric nurses) in the Netherlands. Here, both maternal pertussis vaccination as well as pertussis cocooning has not been implemented. The topic list was based on a literature review and a barrier framework. All interviews were transcribed verbatim and two researchers performed thematic content analysis. Findings The participants’ risk perception, outcome expectations, general vaccination beliefs, moral norms, opinion of others, perceived autonomy, anticipated regret, decisional uncertainty, and perceived organisational barriers were all factors that influenced the intention to accept pertussis vaccination for cocooning. Discussion This study has identified nine perceived determinants that influence the intention to accept pertussis cocooning vaccination. We add the following determinants to the literature: perceived cost-effectiveness (as a concept of outcome expectations), justice (as a concept of moral norms), anticipated regret, and decisional uncertainty. We recommend considering these determinants in vaccination programmes for pertussis cocooning vaccination. Experience, information and trust emerged as predominant themes within these determinants. These themes require particular attention in future research on vaccination acceptance, especially with regard to their role in use and implementation in policy and practice.
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Affiliation(s)
- Olga Visser
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
- * E-mail:
| | - Jeannine L. A. Hautvast
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Koos van der Velden
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marlies E. J. L. Hulscher
- Scientific Institute for Quality of Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
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136
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Fu LY, Zook K, Gingold JA, Gillespie CW, Briccetti C, Cora-Bramble D, Joseph JG, Haimowitz R, Moon RY. Strategies for Improving Vaccine Delivery: A Cluster-Randomized Trial. Pediatrics 2016; 137:peds.2015-4603. [PMID: 27244859 DOI: 10.1542/peds.2015-4603] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE New emphasis on and requirements for demonstrating health care quality have increased the need for evidence-based methods to disseminate practice guidelines. With regard to impact on pediatric immunization coverage, we aimed to compare a financial incentive program (pay-for-performance [P4P]) and a virtual quality improvement technical support (QITS) learning collaborative. METHODS This single-blinded (to outcomes assessor), cluster-randomized trial was conducted among unaffiliated pediatric practices across the United States from June 2013 to June 2014. Practices received either the P4P or QITS intervention. All practices received a Vaccinator Toolkit. P4P practices participated in a tiered financial incentives program for immunization coverage improvement. QITS practices participated in a virtual learning collaborative. Primary outcome was percentage of all needed vaccines received (PANVR). We also assessed immunization up-to-date (UTD) status. RESULTS Data were analyzed from 3,147 patient records from 32 practices. Practices in the study arms reported similar QI activities (∼6 to 7 activities). We found no difference in PANVR between P4P and QITS (mean ± SE, 90.7% ± 1.1% vs 86.1% ± 1.3%, P = 0.46). Likewise, there was no difference in odds of being UTD between study arms (adjusted odds ratio 1.02, 95% confidence interval 0.68 to 1.52, P = .93). In within-group analysis, patients in both arms experienced nonsignificant increases in PANVR. Similarly, the change in adjusted odds of UTD over time was modest and nonsignificant for P4P but reached significance in the QITS arm (adjusted odds ratio 1.28, 95% confidence interval 1.02 to 1.60, P = .03). CONCLUSIONS Participation in either a financial incentives program or a virtual learning collaborative led to self-reported improvements in immunization practices but minimal change in objectively measured immunization coverage.
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Affiliation(s)
- Linda Y Fu
- Goldberg Center for Community Pediatric Health and Center for Translational Science, Children's National Health System, Washington, District of Columbia; The George Washington University School of Medicine, Washington, District of Columbia;
| | - Kathleen Zook
- Goldberg Center for Community Pediatric Health and SciMetrika, LLC, Silver Spring, Maryland
| | | | - Catherine W Gillespie
- Center for Translational Science, Children's National Health System, Washington, District of Columbia; The George Washington University School of Medicine, Washington, District of Columbia; AARP Public Policy Institute, Washington, District of Columbia
| | - Christine Briccetti
- Goldberg Center for Community Pediatric Health and The George Washington University School of Medicine, Washington, District of Columbia
| | - Denice Cora-Bramble
- Goldberg Center for Community Pediatric Health and Center for Translational Science, Children's National Health System, Washington, District of Columbia; The George Washington University School of Medicine, Washington, District of Columbia
| | - Jill G Joseph
- Betty Irene Moore School of Nursing, University of California Davis, Sacramento, California; and
| | - Rachel Haimowitz
- The George Washington University School of Medicine, Washington, District of Columbia
| | - Rachel Y Moon
- Goldberg Center for Community Pediatric Health and Center for Translational Science, Children's National Health System, Washington, District of Columbia; The George Washington University School of Medicine, Washington, District of Columbia; Division of General Pediatrics, University of Virginia School of Medicine, Charlottesville, Virgina
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137
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Abstract
Vaccines are some of if not the most successful public health endeavors ever put into practice. Countless lives have been saved and the occurrences of vaccine preventable diseases are at a fraction of the rate experienced before vaccines. Vaccines and the realization of their compulsory scheduling are highly studied, safe, and purposeful. Despite these realities, there are an alarming number of parents who do not permit the vaccination of their children as scheduled. This is known in the health community as vaccine hesitancy and commonly portrayed in popular media as anti-vaccination sediment. This analysis opens with the topic as it was addressed during a September 2015 debate for the Republic Party's 2016 presidential nomination. Some key historical aspects of vaccine hesitancy are presented. This history leads to a description of the 2014-2015 measles outbreak in California. The factors that aide in the recruitment of under vaccination are then explored. Finally, select strategies to control, combat, and potentially attenuate vaccine hesitancy are presented.
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Affiliation(s)
- David Callender
- a School of Public Health and Health Sciences, University of Massachusetts Amherst , Amherst , MA , USA
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138
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Collange F, Verger P, Launay O, Pulcini C. Knowledge, attitudes, beliefs and behaviors of general practitioners/family physicians toward their own vaccination: A systematic review. Hum Vaccin Immunother 2016; 12:1282-92. [PMID: 27078723 PMCID: PMC4963063 DOI: 10.1080/21645515.2015.1138024] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 12/17/2015] [Accepted: 12/29/2015] [Indexed: 12/25/2022] Open
Abstract
CONTEXT General practitioners and family physicians (GP/FPs) play a key role in the vaccination of the public in many countries and serve as role models for their patients through their own health behaviors. OBJECTIVES AND METHODS a) To search for and document recommended/mandated vaccines for GP/FPs in high-income countries; b) To systematically search and review the literature on these physicians' knowledge, attitudes, beliefs, and behaviors (KABB) toward their own vaccination with the recommended/mandated vaccines and the factors determining it. RESULTS a) The 14 countries included recommended or mandated as many as 12 vaccines; b) The systematic review identified 11 studies published in the last 10 y. All considered seasonal influenza vaccination but differed in the variables investigated. DISCUSSION/CONCLUSIONS This review highlights the need for further studies on this topic, including qualitative and interventional studies (based on behavior change theories). These should cover occupational vaccines and determinants known to be associated with vaccine hesitancy.
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Affiliation(s)
- Fanny Collange
- Aix Marseille University, URMITE, IRD 198, UMR CNRS 7278, INSERM 1095, Faculté de Médecine, Marseille, France
- INSERM, UMR912 “Economics and Social Sciences Applied to Health & Analysis of Medical Information” (SESSTIM), Marseille, France
- ORS PACA, Southeastern Health Regional Observatory, Marseille, France
| | - Pierre Verger
- INSERM, UMR912 “Economics and Social Sciences Applied to Health & Analysis of Medical Information” (SESSTIM), Marseille, France
- ORS PACA, Southeastern Health Regional Observatory, Marseille, France
- INSERM, F-CRIN, Innovative Clinical Research Network in Vaccinology (I-REIVAC), CIC 1417, GH Cochin Broca Hôtel Dieu, Paris, France
| | - Odile Launay
- INSERM, F-CRIN, Innovative Clinical Research Network in Vaccinology (I-REIVAC), CIC 1417, GH Cochin Broca Hôtel Dieu, Paris, France
- Paris Descartes University, Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Fédération des Maladies Infectieuses, CIC Cochin Pasteur, Paris, France
| | - Céline Pulcini
- CHU de Nancy, Service de Maladies Infectieuses et Tropicales, Hôpitaux de Brabois, Vandœuvre-lès-Nancy Cedex, France
- Lorraine University, Paris Descartes University, EA 4360 APEMAC, Vandœuvre-lès-Nancy Cedex, France
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139
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Hoekstra S, Margolis L. The Importance of the Nursing Role in Parental Vaccine Decision Making. Clin Pediatr (Phila) 2016; 55:401-3. [PMID: 26810621 DOI: 10.1177/0009922815627348] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
| | - Lewis Margolis
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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140
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Stahl JP, Cohen R, Denis F, Gaudelus J, Martinot A, Lery T, Lepetit H. The impact of the web and social networks on vaccination. New challenges and opportunities offered to fight against vaccine hesitancy. Med Mal Infect 2016; 46:117-22. [PMID: 26987960 DOI: 10.1016/j.medmal.2016.02.002] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 02/11/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Vaccine hesitancy is a growing and threatening trend, increasing the risk of disease outbreaks and potentially defeating health authorities' strategies. We aimed to describe the significant role of social networks and the Internet on vaccine hesitancy, and more generally on vaccine attitudes and behaviors. METHODS Presentation and discussion of lessons learnt from: (i) the monitoring and analysis of web and social network contents on vaccination; (ii) the tracking of Google search terms used by web users; (iii) the analysis of Google search suggestions related to vaccination; (iv) results from the Vaccinoscopie(©) study, online annual surveys of representative samples of 6500 to 10,000 French mothers, monitoring vaccine behaviors and attitude of French parents as well as vaccination coverage of their children, since 2008; and (v) various studies published in the scientific literature. RESULTS Social networks and the web play a major role in disseminating information about vaccination. They have modified the vaccination decision-making process and, more generally, the doctor/patient relationship. The Internet may fuel controversial issues related to vaccination and durably impact public opinion, but it may also provide new tools to fight against vaccine hesitancy. CONCLUSION Vaccine hesitancy should be fought on the Internet battlefield, and for this purpose, communication strategies should take into account new threats and opportunities offered by the web and social networks.
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Affiliation(s)
- J-P Stahl
- Infectious Diseases Department, University of Grenoble, CHU de Grenoble, Grenoble, France.
| | - R Cohen
- CHU de Créteil, 40, avenue de Verdun, 94010 Créteil cedex, France
| | - F Denis
- CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France
| | - J Gaudelus
- Hôpital Jean-Verdier, hôpitaux universitaires Paris-Deine-Saint-Denis, 93140 Bondy, France; Université Paris-XIII, AP-HP, Paris, France
| | - A Martinot
- University of Lille, CHU de Lille, EA 2694, 2, avenue Oscar-Lambret, 59037 Lille cedex, France
| | - T Lery
- GSK vaccines, 100, route de Versailles, 78163 Marly-le-Roi cedex, France
| | - H Lepetit
- Institut des Mamans, 2, rue Balny-d'Avricourt, 75017 Paris, France
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141
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Atkinson KM, Ducharme R, Westeinde J, Wilson SE, Deeks SL, Pascali D, Wilson K. Vaccination attitudes and mobile readiness: A survey of expectant and new mothers. Hum Vaccin Immunother 2016; 11:1039-45. [PMID: 25714388 PMCID: PMC4514377 DOI: 10.1080/21645515.2015.1009807] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Sub-optimal vaccination coverage and recent outbreaks of vaccine-preventable diseases serve as a reminder that vaccine hesitancy remains a concern. ImmunizeCA, a new smartphone app to help track immunizations, may address several reasons for not vaccinating. We conducted a study to describe demographic variables, attitudes, beliefs and information sources regarding pediatric vaccination in a sample of childbearing women who were willing to download an immunization app. We also sought to measure their current mobile usage behaviors and determine if there is an association between participant demographics, attitudes, beliefs and information sources regarding pediatric vaccination and mobile usage. We recruited participants using a combination of passive and active methods at a tertiary care hospital in Ottawa, Canada. We used surveys to collect demographic information, examine attitudes, behavior, and information sources regarding immunization and self-reported mobile phone usage. A total of 54 women participated. The majority had positive attitudes toward vaccination (96%) and intended to vaccinate their children (98%). Participants were interested in information on pediatric vaccination (94%), and found information from public health the most reliable and accessible (78%). Participants also trusted immunization information from their doctor or nurse and public health (83%) more than other sources. There was variability in participant use of mobile apps for other purposes. The median participant mobile readiness score was 3.2. We found no significant associations between participant age, behavior and attitudes regarding vaccination and mobile readiness scores. This is the first evaluation of mobile readiness for a smartphone app to track immunizations. Our findings suggest that there exists an opportunity to provide reliable information on vaccination through mobile devices to better inform the public, however predictors of individual engagement with these technologies merits further study.
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Affiliation(s)
- Katherine M Atkinson
- a Clinical Epidemiology Program ; Ottawa Hospital Research Institute ; Ottawa , Canada
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142
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Cacciatore MA, Nowak G, Evans NJ. Exploring The Impact Of The US Measles Outbreak On Parental Awareness Of And Support For Vaccination. Health Aff (Millwood) 2016; 35:334-40. [DOI: 10.1377/hlthaff.2015.1093] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Michael A. Cacciatore
- Michael A. Cacciatore ( ) is an assistant professor in the Department of Advertising and Public Relations at Grady College, University of Georgia, in Athens
| | - Glen Nowak
- Glen Nowak is a professor in the Department of Advertising and Public Relations and director of the Center for Health and Risk Communication, both at Grady College, University of Georgia
| | - Nathaniel J. Evans
- Nathaniel J. Evans is an assistant professor in the Department of Advertising and Public Relations at Grady College, University of Georgia
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143
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Dubé E, Vivion M, Sauvageau C, Gagneur A, Gagnon R, Guay M. "Nature Does Things Well, Why Should We Interfere?": Vaccine Hesitancy Among Mothers. QUALITATIVE HEALTH RESEARCH 2016; 26:411-25. [PMID: 25711847 DOI: 10.1177/1049732315573207] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Parents' decision to use vaccination services is complex and multi-factorial. Of particular interest are "vaccine-hesitant" parents who are in the middle of the continuum between vaccine acceptance and refusal. The objective of this qualitative longitudinal study was to better understand why mothers choose to vaccinate-or not-their newborns. Fifty-six pregnant mothers living in different areas of Quebec (Canada) were interviewed. These interviews gathered information on mothers' views about health and vaccination. Almost half of the mothers were categorized as vaccine-hesitant. A second interview was conducted with these mothers 3 to 11 months after birth to look at their actual decision and behavior concerning vaccination. Our results show the heterogeneity of factors influencing vaccine decision making. Although the majority of vaccine-hesitant mothers finally chose to follow the recommended vaccine schedule for their child, they were still ambivalent and they continued to question their decision.
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Affiliation(s)
- Eve Dubé
- Centre de recherche du CHU de Québec, Québec City, Québec, Canada
| | - Maryline Vivion
- Institut national de santé publique du Québec, Québec City, Québec, Canada
| | - Chantal Sauvageau
- Institut national de santé publique du Québec, Québec City, Québec, Canada
| | | | - Raymonde Gagnon
- Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada
| | - Maryse Guay
- Université de Sherbrooke, Sherbrooke, Québec, Canada
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144
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Kumar D, Chandra R, Mathur M, Samdariya S, Kapoor N. Vaccine hesitancy: understanding better to address better. Isr J Health Policy Res 2016; 5:2. [PMID: 26839681 PMCID: PMC4736490 DOI: 10.1186/s13584-016-0062-y] [Citation(s) in RCA: 131] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 01/25/2016] [Indexed: 11/18/2022] Open
Abstract
Vaccine hesitancy is an emerging term in the socio-medical literature which describes an approach to vaccine decision making. It recognizes that there is a continuum between full acceptance and outright refusal of some or all vaccines and challenges the previous understanding of individuals or groups, as being either anti-vaccine or pro-vaccine. The behaviours responsible for vaccine hesitancy can be related to confidence, convenience and complacency. The causes of vaccine hesitancy can be described by the epidemiological triad i.e. the complex interaction of environmental- (i.e. external), agent- (i.e. vaccine) and host (or parent)- specific factors. Vaccine hesitancy is a complex and dynamic issue; future vaccination programs need to reflect and address these context-specific factors in both their design and evaluation. Many experts are of the view that it is best to counter vaccine hesitancy at the population level. They believe that it can be done by introducing more transparency into policy decision-making before immunization programs, providing up-to-date information to the public and health providers about the rigorous procedures undertaken before introduction of new vaccines, and through diversified post-marketing surveillance of vaccine-related events.
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Affiliation(s)
- Dewesh Kumar
- Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Basni-II, Jodhpur, Rajasthan 342005 India
| | - Rahul Chandra
- Department of Community Medicine, Rohilkhand Medical College and Hospital, Bareilly, U.P, 243006 India
| | - Medha Mathur
- Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Basni-II, Jodhpur, Rajasthan 342005 India
| | - Saurabh Samdariya
- Department of Radiation Oncology, All India Institute of Medical Sciences, Basni-II, Jodhpur, Rajasthan 342005 India
| | - Neelesh Kapoor
- RMNCH + A Scale up project, IPE Global/USAID, Sixth Floor, DSHM, B block, Vikas Bhawan-2, Civil Lines, New Delhi, 110054 India
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145
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Moran MB, Frank LB, Chatterjee JS, Murphy ST, Baezconde-Garbanati L. Information scanning and vaccine safety concerns among African American, Mexican American, and non-Hispanic White women. PATIENT EDUCATION AND COUNSELING 2016; 99:147-53. [PMID: 26321294 PMCID: PMC4691412 DOI: 10.1016/j.pec.2015.08.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 08/10/2015] [Accepted: 08/11/2015] [Indexed: 05/03/2023]
Abstract
OBJECTIVE A significant number of parents delay or refuse vaccinating their children. Incidental exposure to vaccine information (i.e., scanned information) may be an important contributor to anti-vaccine sentiment. This study examines the association between scanned information, trust in health information sources and vaccine safety concerns among African American, Mexican American, and non-Hispanic White women. METHODS Women (N=761) in Los Angeles County were sampled via random digit dial and surveyed regarding use of and trust in health information resources and vaccine safety concerns. RESULTS Analyses indicate that the sources of information associated with vaccine safety concerns varied by ethnicity. Each ethnic group exhibited different patterns of association between trust in health information resources and vaccine safety concerns. CONCLUSIONS Information scanning is associated with beliefs about vaccine safety, which may lead parents to refuse or delay vaccinating their children. These relationships vary by ethnicity. PRACTICE IMPLICATIONS These findings help inform practitioners and policy makers about communication factors that influence vaccine safety concerns. Knowing these sources of information will equip practitioners to better identify women who may have been exposed to anti-vaccine messages and counter these beliefs with effective, vaccine-promoting messages via the most relevant information sources.
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Affiliation(s)
- Meghan Bridgid Moran
- Department of Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA.
| | - Lauren B Frank
- Department of Communication, Portland State University, 520 SW Harrison St., Ste. 440, Portland, OR 97201, USA.
| | - Joyee S Chatterjee
- Gender and Development Studies, School of Environment, Resources and Development, Asian Institute of Technology.
| | - Sheila T Murphy
- Annenberg School for Communication and Journalism, University of Southern California, 3502 Watt Way, Los Angeles, CA 90089, USA.
| | - Lourdes Baezconde-Garbanati
- Institute for Health Promotion and Disease Prevention Research, Department of Preventive Medicine, Division of Health Behavior and Norris Comprehensive Cancer Center, Keck School of Medicine of USC, University of Southern California, 2001 N. Soto St., Los Angeles, CA 90032, USA.
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146
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Chen RT, Shimabukuro TT, Martin DB, Zuber PLF, Weibel DM, Sturkenboom M. Enhancing Vaccine Safety Capacity Globally: A Lifecycle Perspective. Am J Prev Med 2015; 49:S364-76. [PMID: 26590436 DOI: 10.1016/j.amepre.2015.09.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Major vaccine safety controversies have arisen in several countries beginning in the last decades of 20th century. Such periodic vaccine safety controversies are unlikely to go away in the near future as more national immunization programs mature with near elimination of target vaccine-preventable diseases that result in relative greater prominence of adverse events following immunizations, both true reactions and temporally coincidental events. There are several ways in which vaccine safety capacity can be improved to potentially mitigate the impact of future vaccine safety controversies. This paper aims to take a "lifecycle" approach, examining some potential pre- and post-licensure opportunities to improve vaccine safety, in both developed (specifically U.S. and Europe) and low- and middle-income countries.
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Affiliation(s)
- Robert T Chen
- Office of Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States.
| | - Tom T Shimabukuro
- Office of Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - David B Martin
- Office of Biostatistics and Epidemiology, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD, United States
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147
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Chen RT, Shimabukuro TT, Martin DB, Zuber PLF, Weibel DM, Sturkenboom M. Enhancing vaccine safety capacity globally: A lifecycle perspective. Vaccine 2015; 33 Suppl 4:D46-54. [PMID: 26433922 PMCID: PMC4663114 DOI: 10.1016/j.vaccine.2015.06.073] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 06/08/2015] [Accepted: 06/09/2015] [Indexed: 12/22/2022]
Abstract
Major vaccine safety controversies have arisen in several countries beginning in the last decades of 20th century. Such periodic vaccine safety controversies are unlikely to go away in the near future as more national immunization programs mature with near elimination of target vaccine-preventable diseases that result in relative greater prominence of adverse events following immunizations, both true reactions and temporally coincidental events. There are several ways in which vaccine safety capacity can be improved to potentially mitigate the impact of future vaccine safety controversies. This paper aims to take a "lifecycle" approach, examining some potential pre- and post-licensure opportunities to improve vaccine safety, in both developed (specifically U.S. and Europe) and low- and middle-income countries.
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Affiliation(s)
- Robert T Chen
- Office of Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States.
| | - Tom T Shimabukuro
- Office of Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - David B Martin
- Office of Biostatistics and Epidemiology, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD, United States
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148
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Attwell K, Freeman M. I Immunise: An evaluation of a values-based campaign to change attitudes and beliefs. Vaccine 2015; 33:6235-40. [PMID: 26458802 DOI: 10.1016/j.vaccine.2015.09.092] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 09/21/2015] [Accepted: 09/23/2015] [Indexed: 11/29/2022]
Abstract
This paper presents results of a study determining the efficacy of a values based approach to changing vaccination attitudes. It reports an evaluation survey of the "I Immunise" campaign, conducted in Fremantle, Western Australia, in 2014. "I Immunise" explicitly engaged with values and identity; formulated by locals in a community known for its alternative lifestyles and lower-than-national vaccine coverage rates. Data was collected from 304 online respondents. The campaign polarised attitudes towards vaccination and led some to feel more negatively. However, it had an overall positive response with 77% of participants. Despite the campaign only resonating positively with a third of parents who had refused or doubted vaccines, it demonstrates an important in-road into this hard-to-reach group.
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Affiliation(s)
- Katie Attwell
- Immunisation Alliance of Western Australia, Cockburn GP SuperClinic, Success, Western Australia 6164, Australia; Murdoch University, South Street, Murdoch, Western Australia 6150, Australia.
| | - Melanie Freeman
- Immunisation Alliance of Western Australia, Cockburn GP SuperClinic, Success, Western Australia 6164, Australia; Murdoch University, South Street, Murdoch, Western Australia 6150, Australia
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149
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Opel DJ, Mangione-Smith R, Robinson JD, Heritage J, DeVere V, Salas HS, Zhou C, Taylor JA. The Influence of Provider Communication Behaviors on Parental Vaccine Acceptance and Visit Experience. Am J Public Health 2015; 105:1998-2004. [PMID: 25790386 PMCID: PMC4566548 DOI: 10.2105/ajph.2014.302425] [Citation(s) in RCA: 143] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2014] [Indexed: 12/31/2022]
Abstract
OBJECTIVES We investigated how provider vaccine communication behaviors influence parental vaccination acceptance and visit experience. METHODS In a cross-sectional observational study, we videotaped provider-parent vaccine discussions (n = 111). We coded visits for the format providers used for initiating the vaccine discussion (participatory vs presumptive), parental verbal resistance to vaccines after provider initiation (yes vs no), and provider pursuit of recommendations in the face of parental resistance (pursuit vs mitigated or no pursuit). Main outcomes were parental verbal acceptance of recommended vaccines at visit's end (all vs ≥ 1 refusal) and parental visit experience (highly vs lower rated). RESULTS In multivariable models, participatory (vs presumptive) initiation formats were associated with decreased odds of accepting all vaccines at visit's end (adjusted odds ratio [AOR] = 0.04; 95% confidence interval [CI] = 0.01, 0.15) and increased odds of a highly rated visit experience (AOR = 17.3; 95% CI = 1.5, 200.3). CONCLUSIONS In the context of 2 general communication formats used by providers to initiate vaccine discussions, there appears to be an inverse relationship between parental acceptance of vaccines and visit experience. Further exploration of this inverse relationship in longitudinal studies is needed.
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Affiliation(s)
- Douglas J Opel
- Douglas J. Opel, Rita Mangione-Smith, Chuan Zhou, and James A. Taylor are with the Department of Pediatrics, University of Washington School of Medicine, Seattle, WA. Jeffrey D. Robinson is with the Department of Communication, Portland State University, Portland, OR. John Heritage is with Department of Sociology, University of California, Los Angeles. Victoria DeVere and Halle S. Salas are with the Seattle Children's Research Institute, Seattle, WA
| | - Rita Mangione-Smith
- Douglas J. Opel, Rita Mangione-Smith, Chuan Zhou, and James A. Taylor are with the Department of Pediatrics, University of Washington School of Medicine, Seattle, WA. Jeffrey D. Robinson is with the Department of Communication, Portland State University, Portland, OR. John Heritage is with Department of Sociology, University of California, Los Angeles. Victoria DeVere and Halle S. Salas are with the Seattle Children's Research Institute, Seattle, WA
| | - Jeffrey D Robinson
- Douglas J. Opel, Rita Mangione-Smith, Chuan Zhou, and James A. Taylor are with the Department of Pediatrics, University of Washington School of Medicine, Seattle, WA. Jeffrey D. Robinson is with the Department of Communication, Portland State University, Portland, OR. John Heritage is with Department of Sociology, University of California, Los Angeles. Victoria DeVere and Halle S. Salas are with the Seattle Children's Research Institute, Seattle, WA
| | - John Heritage
- Douglas J. Opel, Rita Mangione-Smith, Chuan Zhou, and James A. Taylor are with the Department of Pediatrics, University of Washington School of Medicine, Seattle, WA. Jeffrey D. Robinson is with the Department of Communication, Portland State University, Portland, OR. John Heritage is with Department of Sociology, University of California, Los Angeles. Victoria DeVere and Halle S. Salas are with the Seattle Children's Research Institute, Seattle, WA
| | - Victoria DeVere
- Douglas J. Opel, Rita Mangione-Smith, Chuan Zhou, and James A. Taylor are with the Department of Pediatrics, University of Washington School of Medicine, Seattle, WA. Jeffrey D. Robinson is with the Department of Communication, Portland State University, Portland, OR. John Heritage is with Department of Sociology, University of California, Los Angeles. Victoria DeVere and Halle S. Salas are with the Seattle Children's Research Institute, Seattle, WA
| | - Halle S Salas
- Douglas J. Opel, Rita Mangione-Smith, Chuan Zhou, and James A. Taylor are with the Department of Pediatrics, University of Washington School of Medicine, Seattle, WA. Jeffrey D. Robinson is with the Department of Communication, Portland State University, Portland, OR. John Heritage is with Department of Sociology, University of California, Los Angeles. Victoria DeVere and Halle S. Salas are with the Seattle Children's Research Institute, Seattle, WA
| | - Chuan Zhou
- Douglas J. Opel, Rita Mangione-Smith, Chuan Zhou, and James A. Taylor are with the Department of Pediatrics, University of Washington School of Medicine, Seattle, WA. Jeffrey D. Robinson is with the Department of Communication, Portland State University, Portland, OR. John Heritage is with Department of Sociology, University of California, Los Angeles. Victoria DeVere and Halle S. Salas are with the Seattle Children's Research Institute, Seattle, WA
| | - James A Taylor
- Douglas J. Opel, Rita Mangione-Smith, Chuan Zhou, and James A. Taylor are with the Department of Pediatrics, University of Washington School of Medicine, Seattle, WA. Jeffrey D. Robinson is with the Department of Communication, Portland State University, Portland, OR. John Heritage is with Department of Sociology, University of California, Los Angeles. Victoria DeVere and Halle S. Salas are with the Seattle Children's Research Institute, Seattle, WA
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150
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Forbes TA, McMinn A, Crawford N, Leask J, Danchin M. Vaccination uptake by vaccine-hesitant parents attending a specialist immunization clinic in Australia. Hum Vaccin Immunother 2015; 11:2895-903. [PMID: 26366978 DOI: 10.1080/21645515.2015.1070997] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Vaccine hesitancy (VH) is an issue of global concern. The quality of communication between healthcare providers and parents can influence parental immunization acceptance. We aimed to describe immunization uptake following specialist immunization clinic (SIC) consultation for Australian children of VH parents as a cohort, and according to pre-clinic parental position on immunization. At a single tertiary pediatric SIC (RCH, Melbourne) a retrospective descriptive study classified VH families according to 3 proposed parental positions on immunization at initial clinic attendance. Immunization status at follow up was ascertained via the Australian Children's Immunization Register and National HPV Program Register and compared between groups. Of the VH cohort, 13/38 (34%) families were classified as hesitant, 21 (55%) as late/selective vaccinators and 4 (11%) as vaccine refusers. Mean follow up post-SIC attendance was 14.5 months. For the overall VH cohort, the majority chose selective immunization (42%) following SIC consultation. When analyzed by pre-clinic parental position on immunization, there was a trend for hesitant families to proceed with full immunization, selective families to continue selective immunization and refusing families to remain unimmunised (p < 0.0001). The most commonly omitted vaccines were hepatitis B (66%) and Haemophilus influenzae type B (55%), followed by the meningococcal C conjugate vaccine (53%) and measles, mumps and rubella vaccine (53%). Immunization outcome appears to correlate with pre-clinic parental position on immunization for the majority of families attending a SIC in Australia, with selective immunization the most common outcome. Tailored communication approaches based on parental position on immunization may optimise clinic resources and engagement of families, but require prospective research evaluation.
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Affiliation(s)
- Thomas A Forbes
- a Department of Nephrology ; Royal Children's Hospital ; Parkville , Victoria , Australia
| | - Alissa McMinn
- b SAEFVIC and Vaccine and Immunisation Research Group; Murdoch Children's Research Institute ; Parkville , VIC Australia
| | - Nigel Crawford
- b SAEFVIC and Vaccine and Immunisation Research Group; Murdoch Children's Research Institute ; Parkville , VIC Australia.,c Department of General Medicine ; Royal Children's Hospital ; Parkville , Victoria , Australia.,d Murdoch Childrens Research Institute; Parkville, Victoria, Australia ; Department of Pediatrics and School of Population and Global Health; University of Melbourne ; Parkville , VIC Australia
| | - Julie Leask
- e School of Public health; University of Sydney ; New South Wales , Australia
| | - Margie Danchin
- b SAEFVIC and Vaccine and Immunisation Research Group; Murdoch Children's Research Institute ; Parkville , VIC Australia.,c Department of General Medicine ; Royal Children's Hospital ; Parkville , Victoria , Australia.,d Murdoch Childrens Research Institute; Parkville, Victoria, Australia ; Department of Pediatrics and School of Population and Global Health; University of Melbourne ; Parkville , VIC Australia
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