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O'Leary ST, Opel DJ, Cataldi JR, Hackell JM. Strategies for Improving Vaccine Communication and Uptake. Pediatrics 2024; 153:e2023065483. [PMID: 38404211 DOI: 10.1542/peds.2023-065483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2023] [Indexed: 02/27/2024] Open
Abstract
Vaccines have led to a significant decrease in rates of vaccine-preventable diseases and have made a significant impact on the health of children. However, some parents express concerns about vaccine safety and the necessity of vaccines. The concerns of parents range from hesitancy about some immunizations to refusal of all vaccines. This clinical report provides information about the scope and impact of the problem, the facts surrounding common vaccination concerns, and the latest evidence regarding effective communication techniques for the vaccine conversation. After reading this clinical report, readers can expect to: Understand concepts and underlying determinants of vaccine uptake and vaccine hesitancy.Understand the relationship between vaccine hesitancy and costs of preventable medical care.Recognize and address specific concerns (eg, vaccine safety) with caregivers when hesitancy is present.
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Affiliation(s)
- Sean T O'Leary
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine/Children's Hospital Colorado, Aurora, Colorado
| | - Douglas J Opel
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Research Institute; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Jessica R Cataldi
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine/Children's Hospital Colorado, Aurora, Colorado
| | - Jesse M Hackell
- Department of Pediatrics, New York Medical College, Valhalla, New York
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Nguyen CG, Pogemiller MI, Cooper MT, Garbe MC, Darden PM. Characteristics of Oklahoma Pediatricians Who Dismiss Families for Refusing Vaccines. Clin Pediatr (Phila) 2023; 62:24-32. [PMID: 35883261 DOI: 10.1177/00099228221108801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Vaccine refusal is increasing. Objectives were to assess frequency of declining or dismissing patients who refuse vaccines, which vaccine(s) prompt pediatricians to decline/dismiss patients, and demographics of pediatricians who decline/dismiss patients. Active members of the Oklahoma American Academy of Pediatricians (AAP) were surveyed. Chi-square tests with non-overlapping 95% confidence intervals compared proportions of providers across various metrics. In all, 47% (48/103) versus 35% (34/98) reported declining versus dismissing patients for refusing vaccines, respectively. Pediatricians were unlikely to decline/dismiss patients if they refused influenza, human papilloma virus (HPV), or MenB vaccines. Pediatricians with more years in practice were less likely to decline 15% (9/62) versus 44% (16/36), P = 0.002 and dismiss 8% (5/62) versus 33% (12/36), P = 0.002 patients. Rural pediatricians were less likely than urban to decline 12% (2/17) versus 29% (26/89), P = NS and dismiss patients 0% (0/17) versus 21% (19/89), P = 0.04. Dismissing/declining patients for vaccine refusal is more common among Oklahoma pediatricians than nationally reported. Patterns differ by practice setting, years in practice, and specific vaccine refused.
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Affiliation(s)
| | - Mark I Pogemiller
- University of Oklahoma College of Medicine, Oklahoma City, OK, USA.,Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.,Section of General and Community Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Michael T Cooper
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.,Section of General and Community Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - M Connor Garbe
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.,Section of General and Community Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Paul M Darden
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.,Section of General and Community Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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3
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Pediatric primary care immunization policies in New York State. Vaccine 2022; 40:1458-1463. [DOI: 10.1016/j.vaccine.2022.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 01/21/2022] [Accepted: 01/23/2022] [Indexed: 11/18/2022]
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Navin MC, Wasserman JA, Opel DJ. Reasons to Accept Vaccine Refusers in Primary Care. Pediatrics 2020; 146:peds.2020-1801. [PMID: 33159001 DOI: 10.1542/peds.2020-1801] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Mark C Navin
- Department of Philosophy, Oakland University, Rochester, Michigan; .,Departments of Foundational Medical Studies and
| | - Jason A Wasserman
- Departments of Foundational Medical Studies and.,Pediatrics, Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Douglas J Opel
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington; and.,Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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Mills K, Nilsen K. Kansas Family Physicians Perceptions of Parental Vaccination Hesitancy. Kans J Med 2020; 13:248-259. [PMID: 33173560 PMCID: PMC7651789 DOI: 10.17161/kjm.vol13.14761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 07/22/2020] [Indexed: 11/24/2022] Open
Abstract
Introduction In the past few decades, patients expressing the idea that vaccines are unsafe or unneeded have been experienced increasingly by physicians and other healthcare providers. Discussions with patients regarding their reasons for vaccine refusals are important, as it may provide information that can be utilized in an intervention to increase vaccination rates and combat the spread of diseases that are making a resurgence in the United States. The main objective of this study was to explore the perceptions of family physicians as to why parents in Kansas may be vaccine hesitant. Methods An electronic survey was distributed to family physicians in the State of Kansas via the University of Kansas School of Medicine-Wichita Family Medicine Research and Data Information Office (FM RADIO). Several aspects of physician perceptions regarding patients’ vaccine hesitancy were measured in this study, including vaccines that are most often refused, reasons for refusing vaccinations, as well as what responses physicians employ when presented with vaccine concerns. Results The majority of physicians surveyed have experienced vaccine hesitancy or refusal in their practice, and the human papillomavirus (HPV) and flu vaccines were reported to be the primary vaccines refused for children. In addition, physicians reported frequently employing various practices in response to vaccine refusals, including requiring parents to sign a form (40%) and dismissing families from their practice (1.5%). Physician perceptions on the reasons as to why parents/guardians refuse vaccinations also were measured, and the most common response was that parents possess a fear of long-term complications for their children as a result of vaccines (74%). Additionally, the three most commonly refused vaccines were HPV, influenza, and measles, mumps, and rubella. Conclusion Physicians must not only deal with time constraints that vaccine hesitant discussions require, but also must try and implement discussions or interventions suited to the varying reasons why parents/guardians refuse vaccines to convince parents of their safety. The results suggested that vaccine refusals by parents/guardians seemed to be affecting Kansas family physicians’ clinics in more than one way. This study could be a useful tool to help physicians better understand why vaccine refusals occur and be able to combat unwarranted concerns about vaccines.
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Affiliation(s)
- Kale Mills
- University of Kansas School of Medicine-Wichita, Department of Family and Community Medicine, Wichita, KS
| | - Kari Nilsen
- University of Kansas School of Medicine-Wichita, Department of Family and Community Medicine, Wichita, KS
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Abstract
PURPOSE OF REVIEW In the wake of multiple recent outbreaks of the measles and other vaccine-preventable diseases, it is crucial to understand and address parental concerns about vaccination. The purposes of this review are: to identify the causes of vaccine resistance, to elucidate the variables that have led to the success or failure of interventions to date, and to consider implications for pediatricians treating children whose parents are vaccination-resistant. RECENT FINDINGS Recent research draws on insights from cognitive science to understand vaccine resistance and to develop more effective interventions. Studies show that vaccine resistors are more likely to value lifestyle liberty, to favor individualistic over hierarchical worldviews, and to believe in conspiracy theories. Interventions that seek primarily to correct erroneous beliefs about the dangers of vaccination are likely to fail or even backfire. On the other hand, intervention strategies, such as motivational interviewing, in which the provider elicits and shows respect for parents' values and concerns while empowering them to make well informed and well reasoned decisions, are more likely to be successful. Parents cite a trusting relationship with their pediatrician as the most important factor influencing their decision to vaccinate. SUMMARY Pediatricians are in the best position to successfully apply insights from cognitive science and intervention research to overcome vaccination-hesitancy.
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Nold L, Deem MJ. A Simulation Experience for Preparing Nurses to Address Refusal of Childhood Vaccines. J Nurs Educ 2020; 59:222-226. [DOI: 10.3928/01484834-20200323-09] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 11/25/2019] [Indexed: 11/20/2022]
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Deem MJ, Kronk RA, Staggs VS, Lucas D. Nurses' Perspectives on the Dismissal of Vaccine-Refusing Families From Pediatric and Family Care Practices. Am J Health Promot 2020; 34:622-632. [PMID: 32077306 DOI: 10.1177/0890117120906971] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE Dismissal of families who refuse mandated childhood vaccines from pediatric practices has become more common among US pediatricians over the past 2 decades. While nurses (registered nurses [RNs] and advanced practice registered nurses [APRNs]) often are the first health-care professional to encounter parents' vaccine hesitancy and serve as a primary source of information, there are no published data on nurses' perspectives on dismissal as a response to vaccine refusal. This study examined nurses' perspectives on dismissal of vaccine-refusing families from primary care practices. DESIGN Cross-sectional survey administered electronically from February to September 2018. Data analysis was conducted from November 2018 to March 2019. SETTING Data were collected electronically from a national sample of nurses. SUBJECTS A convenience sample of 488 primary care nurses (74% APRNs) was recruited and enrolled in the study through collaboration with 4 professional nursing associations. MEASURE AND ANALYSIS A cross-sectional survey was conducted from February to September 2018. We explored correlates of nurses' (n = 488) attitudes toward dismissal by modeling attitude scores as a function of practice and respondent characteristics. We also modeled odds of encountering vaccine refusal and odds of reporting dismissal of a vaccine-refusing family in the last 12 months, each as a function of respondents' practice characteristics. RESULTS Eighty-four percent of respondents encountered vaccine refusal in the previous 12 months, and 22% reported that their practice had dismissed a vaccine-refusing family within the previous 12 months. Twenty-eight percent agreed/strongly agreed that they would dismiss or support a decision to dismiss families who refuse all vaccines, and 12% supported dismissal of families for refusal of some but not all vaccines. Thirty-nine percent of respondents disagreed/strongly disagreed with dismissing families who refuse all vaccines, and 50% disagreed/strongly disagreed with dismissal for refusal of some but not all. CONCLUSION Almost all nurses working in primary care encounter vaccine refusal, and most consider all Centers for Disease Control and Prevention-recommended childhood vaccines to be important to public health. There is significant polarization of nurses' attitudes toward the appropriateness of dismissal as a response to vaccine refusal. We recommend the development of professional nursing guidelines for responding to vaccine refusal. However, because there are no data on the community health impact of dismissal policies, we recommend further research on outcomes of dismissal policies to inform such guidelines.
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Affiliation(s)
- Michael J Deem
- School of Nursing, Duquesne University, Pittsburgh, PA, USA.,Center for Healthcare Ethics, Duquesne University, Pittsburgh, PA, USA
| | | | - Vincent S Staggs
- Biostatistics and Epidemiology, Health Services and Outcomes Research, Children's Mercy Hospital, Kansas City, MO, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Denise Lucas
- School of Nursing, Duquesne University, Pittsburgh, PA, USA
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Garcia TB, O'Leary ST. Dismissal policies for vaccine refusal among US physicians: a literature review. Hum Vaccin Immunother 2020; 16:1189-1193. [PMID: 32078411 DOI: 10.1080/21645515.2020.1724742] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Childhood vaccination is one of the greatest public health achievements of the 20th century, yet increasingly, parents question the safety of and need for vaccines. This has led to increased rates of vaccine delay and refusal and outbreaks of vaccine-preventable diseases. Physicians struggle with how to respond to families who refuse vaccines, as there are few known effective interventions to convince a family to vaccinate. In the United States, the practice of dismissing families for vaccine refusal appears to be increasing as a strategy for dealing with vaccine refusal. In this review, we review the literature surrounding this controversial practice, starting with the impact that vaccine-refusing families have on medical practices, followed by a review of dismissal policies of US physicians, and ending with a discussion of the ethics of this practice.
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Affiliation(s)
- Tamara B Garcia
- Department of Pediatrics, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
| | - Sean T O'Leary
- Department of Pediatrics, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA.,Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), Aurora, CO, USA
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Forster M. Ethical position of medical practitioners who refuse to treat unvaccinated children. JOURNAL OF MEDICAL ETHICS 2019; 45:552-555. [PMID: 31249107 DOI: 10.1136/medethics-2019-105379] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 06/02/2019] [Accepted: 06/13/2019] [Indexed: 06/09/2023]
Abstract
Recent reports in Australia have suggested that some medical practitioners are refusing to treat children who have not been vaccinated, a practice that has been observed in the USA and parts of Europe for some years. This behaviour, if it is indeed occurring in Australia, has not been supported by the Australian Medical Association, although there is broad support for medical practitioners in general having the right to conscientious objection. This paper examines the ethical underpinnings of conscientious objection and whether the right to conscientious objection can be applied to the refusal to treat unvaccinated children. The implications of such a decision will also be discussed, to assess whether refusal to treat unvaccinated children is ethically justifiable. The best interests of both existing and new patients are crucially important in a doctor's practice, and the tension between these two groups of patients are contemplated in the arguments below. It is argued that on balance, the refusal to treat unvaccinated children constitutes unjustified discrimination.
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Navin MC, Kozak AT, Deem MJ. Perspectives of public health nurses on the ethics of mandated vaccine education. Nurs Outlook 2019; 68:62-72. [PMID: 31375346 DOI: 10.1016/j.outlook.2019.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 05/06/2019] [Accepted: 06/21/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Since 2015, Michigan has required parents who request nonmedical exemptions (NMEs) from school or daycare immunization mandates to receive education from local public health staff (usually nurses). This is unlike most other US states that have implemented mandatory immunization counseling, which require physicians to document immunization education, or which provide online instruction. PURPOSE To attend to the activity and dispositions of the public health staff who provide "waiver education". METHOD This study reports results of focus group interviews with 39 of Michigan's vaccine waiver educators (37 nurses), conducted during 2016 and 2017, and analyzed in 2018. FINDINGS Four themes emerged from analysis of the transcripts of these interviews: Participants had (1) complex and nuanced observations and evaluations of parents' judgments and feelings about vaccines and vaccine education; (2) sympathetic attitudes about alternative vaccine schedules; (3) critical and supportive evaluations of institutional policies and the background political context of immunization education; and (4) consistent commitments to respect parents, affirm their values, and protect their rights. DISCUSSION These results show that public health nurses are sensitive to the burdens mandatory immunization education places on families, the motivations for parents' requests for nonmedical exemptions, and the values implicated by personal immunization decisions and government immunization policies. In light of the unique training, experiences, and public reputation of nurses, there is good reason for additional investigation into the roles that nurses can play in immunization education and in vaccine mandate policies, more generally.
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Affiliation(s)
- Mark C Navin
- Department of Philosophy, Oakland University, Rochester, MI.
| | - Andrea T Kozak
- Department of Psychology, Oakland University, Rochester, MI
| | - Michael J Deem
- School of Nursing, Duquesne University, Pittsburgh, PA; Center for Healthcare Ethics, Duquesne University, Pittsburgh, PA
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Marshall GS. Vaccine Hesitancy, History, and Human Nature: The 2018 Stanley A. Plotkin Lecture. J Pediatric Infect Dis Soc 2019; 8:1-8. [PMID: 33513237 DOI: 10.1093/jpids/piy082] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 08/06/2018] [Indexed: 12/11/2022]
Abstract
Navigating the waters of vaccine hesitancy requires a view towards history and a deep understanding of how humans think. Getting children vaccinated is as much, or more, about connecting with people as it is about communicating scientific information.
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Affiliation(s)
- Gary S Marshall
- Division of Pediatric Infectious Diseases, University of Louisville School of Medicine, Kentucky
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Affiliation(s)
- Michael J Deem
- School of Nursing, Duquesne University, Pittsburgh, Pennsylvania.,Center for Healthcare Ethics, Duquesne University, Pittsburgh, Pennsylvania
| | - Mark C Navin
- Department of Philosophy, Oakland University, Rochester, Michigan
| | - John D Lantos
- Bioethics Center, Children's Mercy Hospital, Kansas City, Missouri.,School of Medicine, University of Missouri, Kansas City
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Affiliation(s)
- Gary S Marshall
- University of Louisville School of Medicine, Louisville, Kentucky
| | - Sean T O'Leary
- University of Colorado Anschutz Medical Campus/Children's Hospital Colorado, Aurora
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MacDonald NE, Harmon S, Dube E, Taylor B, Steenbeek A, Crowcroft N, Graham J. Is physician dismissal of vaccine refusers an acceptable practice in Canada? A 2018 overview. Paediatr Child Health 2018; 24:92-97. [PMID: 30996599 DOI: 10.1093/pch/pxy116] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 06/28/2018] [Indexed: 12/25/2022] Open
Abstract
Despite robust evidence that routine immunization is effective and safe, some parents refuse some or all vaccines for their children. In 2007, concern that Canadian paediatricians and family physicians might be considering dismissal of vaccine refusers from their practices prompted an ethical, legal, and public health analysis which concluded that dismissal was professionally problematic. We now reassess this important issue in the Canadian context updating ethical, legal, and public health considerations highlighting changes since 2007. In light of the recent strengthening of Ontario's school immunization requirements that include stiffer steps to qualify for a medical, conscience, or religious belief exemption, physicians and health care workers may be under more pressure from vaccine refusers in their practice leading some to contemplate dismissal or even consider no longer offering immunizations at all in their practice. Given the challenges that vaccine refusers may present, we offer an overview for managing vaccine refusal by parents/patients in a medical practice.
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Affiliation(s)
- Noni E MacDonald
- Department of Pediatrics, Dalhousie University, IWK Health Centre, Halifax, Nova Scotia
| | - Shawn Harmon
- Department of Pediatrics, Dalhousie University, IWK Health Centre, Halifax, Nova Scotia.,JK Mason Institute for Medicine, Life Sciences and Law, University of Edinburgh, Edinburgh, UK
| | - Eve Dube
- Institut National de Santé Publique du Québec and Université Laval, Québec, Québec
| | - Beth Taylor
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, Nova Scotia
| | - Audrey Steenbeek
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, Nova Scotia
| | - Natasha Crowcroft
- Public Health Ontario, Laboratory Medicine and Pathobiology and Dalla Lana School of Public Health University of Toronto, Toronto Ontario
| | - Janice Graham
- Department of Pediatrics, Dalhousie University, IWK Health Centre, Halifax, Nova Scotia.,Technoscience and Regulation Research Unit, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia
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