Face to face interventions for informing or educating parents about early childhood vaccination

Parental perceptions, attitudes, and beliefs regarding vaccination of children aged 0-5 years: A qualitative study of hill-tribe communities, Thailand

The widespread availability and use of vaccines have tremendously reduced morbidity and deaths related to infectious diseases globally. However, in hill-tribe communities in Northern Thailand, vaccination rates remain low, and there is limited literature on parental perceptions, attitudes, and beliefs about vaccination for children under five years of age. We conducted a qualitative study employing semi-structured interviews to understand parents' perceptions, attitudes, and beliefs about vaccinations. A purposive sample was used to recruit participants. Data were analyzed using thematic analysis. 74 hill-tribe parents (14 Akha, 11 Hmong, 12 Lahu, 13 Lisu, 12 Karen, and 12 Yao) were interviewed. Four themes emerged from the interviews: 1) traditional beliefs, and practices 2) traumatic experiences, 3) lack of information and effective communication, and 4) trust and support from the community. Findings highlight that it is crucial to build trust by providing knowledge, appropriate information, and advice about vaccinations in order to improve vaccine coverage in children under five years of age in the hill-tribe context.

Development of PIVOT with MI: A motivational Interviewing-Based vaccine communication training for pediatric clinicians

Delay or refusal of childhood vaccines is common and may be increasing. Pediatricians are parents' most trusted source for vaccine information, yet many struggle with how to communicate with parents who resist recommended vaccines. Evidence-based communication strategies for vaccine conversations are lacking. In this manuscript, we describe the development and perceived usefulness of a curriculum to train clinicians on a specific vaccine communication strategy as part of the PIVOT with MI study, a cluster randomized trial testing the effectiveness of this communication strategy on increasing childhood vaccination uptake among 24 pediatric practices in Colorado and Washington. The communication strategy is based on the existing evidence-based communication strategies of a presumptive format for initiating vaccine conversations and use of motivational interviewing if hesitancy persists. Focus groups and semi-structured interviews with pediatric clinicians helped inform the development of the training curriculum, which consisted of an introductory video module followed by 3 training sessions. Between September 2019 and January 2021, 134 pediatric clinicians (92 pediatricians, 42 advanced practice providers) participated in the training as part of the PIVOT with MI study. Of these, 92 % viewed an introductory video module, 93 % attended or viewed a baseline synchronous training, 82 % attended or viewed a 1st refresher training, and 77 % attended or viewed a 2nd refresher training. A follow-up survey was administered August 2020 through March 2021; among respondents (n = 100), >95 % of participants reported that each component of the training program was very or somewhat useful. These data suggest that the PIVOT with MI training intervention is a useful vaccine communication resource with the potential for high engagement among pediatric clinicians.

A study on the blended learning effects on students majoring in preschool education in the post-pandemic era: An example of a research-method course in a Chinese university

The world has gradually entered the post-pandemic era. Although the pandemic has been slowing down, it still has a strong impact on the education scene. Thus, how to provide students with an effective and flexible learning style is currently an important educational issue. This study focused on the implementation of effective teaching to improve the learning effects based on these special circumstances. To ensure a realistic teaching situation, an experiment of blended learning was conducted in a university in the Guangxi Zhuang Autonomous Region of China for a short-term study, based on the consideration of pandemic supervision and control. In this experiment, a single-group quasi-experimental design method, using the extended O-PIRTATD/S model, was adopted in a research-method course designed for students majoring in preschool education. This research-method course was an 8-week flipped course, where the first 4 weeks were online teaching and the last 4 weeks were taught offline, thus combining as a blended learning course. A total of 115 active participants were recruited for this study. Based on the theoretical framework of the belief-action-outcome (BAO) model, five research hypotheses were proposed with the aim of constructing a learning behavior pattern based on cognitive beliefs which could be verified by structural equation modeling. The results of the study were concluded as follows: 1. Academic self-efficacy had a positive impact on learning engagement, but had a negative impact on cognitive load; 2. Cognitive load did not have a significant impact on learning engagement; 3. Learning engagement had a positive impact on the enhancement of academic self-confidence; and 4. Cognitive load had a negative impact on the enhancement of academic self-confidence.

Exploring the Willingness to Accept SARS-CoV-2 Vaccine in a University Population in Southern Italy, September to November 2020

Understanding whether members of the university population are willing to receive a future vaccination against COVID-19 and identifying barriers may help public health authorities to develop effective strategies and interventions to contain COVID-19. This cross-sectional study explored the willingness to accept a future SARS-CoV-2 vaccine in a university population in Southern Italy. The perceived risk level of developing COVID-19 was 6.5 and it was significantly higher among females, younger subjects, and those who agreed/strongly agreed that COVID-19 is a severe disease. Only 21.4% of respondents were not worried at all regarding the safety of the vaccine. Males, not being married/cohabitant, being a faculty member, those who perceived a lower risk of developing COVID-19, and those who did not need information regarding the vaccination against COVID-19 were significantly more likely to have no concern at all regarding the safety of the vaccine. The vast majority (84.1%) were willing to receive a future vaccine against COVID-19. Almost coherently with predictors of concern on the safety of the vaccine, being male, not being married/cohabitant, being a faculty member, not being concerned at all that COVID-19 vaccination might not be safe, and agreeing that COVID-19 can have serious health consequences were significant predictors of the willingness to receive the vaccine against COVID-19. A considerable proportion of the population had a positive willingness to receive the future COVID-19 vaccine, although some concerns have been expressed regarding the effectiveness and safety and public health activities seem necessary to achieve the rate that can lead to the protection of the community.

Cultivating Patient-Physician Communication About Vaccination Through Vaccine Metaphors

The ease of access to misinformation online leaves patients vulnerable to poor decision-making and perplexed as to who serves as a reliable authority in the dissemination of health-related truths. Of prominent concern in twenty-first century medicine, is the communication between physicians and patients regarding vaccines. This cultural circumstance presents a challenge to physicians to be effective and trustworthy communicators, a challenge that entails the development of crucial skills at the earliest stages of medical education. We describe a pedagogical intervention through which medical students are given the educational experience of metaphorical construction to communicate the importance of vaccination.

A blended intervention to promote physical activity, health and work productivity among office employees using intervention mapping: a study protocol for a cluster-randomized controlled trial

Background

Regular participation in moderate-to-vigorous physical activity (MVPA) is related to decreased risk of morbidity and mortality. Among working populations, lack of MVPA may also be a risk factor for absenteeism and presenteeism. Both traditional workplace-based and web-based interventions have been suggested as being effective in promoting participation MVPA, health-related outcomes, and work-related productivity. However, several challenges limit their application in real world contexts. A ‘blended’ intervention approach combining the two intervention strategies is proposed to overcome these limitations. The proposed intervention aims to utilize the blended approach to increase participation in MVPA, health-related outcomes, and work productivity among inactive workers.

Methods

The study will comprise of a three-group cluster randomized controlled trial (cluster-RCT), comprising a three-month actual intervention and a nine-month behavioral follow-up period. The three groups will be: a web-based intervention group, a blended intervention group combining the web-based components with face-to-face workshops and posters, and a control group. Physically inactive office employees (N = 495) from 33 companies (i.e., clusters) will be recruited and randomly assigned to the three groups by cluster randomization. The intervention mapping (IM) framework will be used for selecting and applying effective health behavioral theories and behavioral change techniques (BCTs) to the development, implementation and assessment of the intervention, which will be personally tailored. The primary outcome variable will be objectively-measured MVPA using an accelerometer. Secondary outcomes will consist of indices of health including adiposity, blood pressure, blood sugar, blood lipids, self-reported depression, anxiety, stress, health-related quality of life and work-related variables including absenteeism and presenteeism.

Discussion

The proposed study adopts a robust blended intervention approach that is expected to overcome challenges in applying workplace-based and web-based interventions separately and yield larger effects in promoting MVPA participation, health-related outcomes and work productivity. Improvements in work productivity outcomes will be of particular interest to employers. If more effective, the new blended intervention has the potential to be implemented on a larger scale to benefit workplace populations.

Trial registration

The trial is prospectively registered at the ClinicalTrials.gov PRS (Trial ID: NCT04391270; Date of First Posted: May 18, 2020).

Are formal self-care interventions for healthy people effective? A systematic review of the evidence

Introduction

Preventative interventions are shown to be effective in reducing 40% of the mortality due to unhealthy behaviours and lifestyles. Health-promoting self-care has been recognised as a promising strategy in preventative health. However, self-care research is being done around the self-management of chronic illnesses and the promotion of self-care practices among healthy populations has been overlooked by many healthcare systems.

Method

The study methodology was a systematic review with a narrative synthesis. The search was done through seven academic databases, reference tracking of selected articles and grey literature. The scoping, selection, screening and quality assessments of the articles were reviewed independently by two reviewers.

Results

Sixteen studies met the inclusion criteria. Self-care behaviour, health-promotive lifestyle changes and medical care utilisation were some of the main outcomes evaluated in the studies. Positive effects were seen in increasing self-care and health-promotive behaviours in most interventions although limited or mixed impact was seen in health attitudes, beliefs and utilisation of medical services. Most studies were from high income settings with low-quality study designs. The complexity of the word ‘self-care’ and inconsistencies in the terminology used in health-promotive self-care were significant highlights of the study.

Conclusion

Health-promoting preventative self-care interventions show promise in increasing the well-being of healthy people. However, the methodological drawbacks limit the generalisability of the findings. As the demand for self-care interventions increases, the lack of a formal globally accepted definition and framework and complexity of behaviour change are key limitations to consider moving forward.

A childhood immunization education program for parents delivered during late pregnancy and one-month postpartum: a randomized controlled trial

Background

Improved immunization rates have reduced the incidence of vaccine-preventable diseases (VPDs) in advanced nations. Japan’s unique vaccination system classifies vaccines into routine vaccines ostensibly required under the Preventive Vaccination Law and recommended but optional vaccines, although all vaccines are in fact voluntary. In Japan, low immunization rates, particularly for optional vaccines, have resulted in high rates of sequelae and death. The decision as to whether a child will receive a vaccine depends on the parents, who must obtain information, make inquiries, and make the required payment, the last of which is a major barrier. This randomized, controlled trial was conducted to evaluate the effectiveness of an immunization education program designed to meet mothers’ needs.

Methods

This randomized controlled trial assigned pregnant women to intervention or control groups. The intervention was individual education sessions involving the children’s fathers in shared decision-making on whether or not to immunize their child. A survey was conducted before and after the intervention. Data were analyzed using the intention-to-treat principle.

Results

Of 225 pregnant women, 175 (78%) participated and 171 replied to the post-survey. At age 3 months, intervention infants had higher self-reported immunization rates for hepatitis B virus vaccine (76% vs. 49%; P < 0.001) and rotavirus vaccine (84% vs. 68%; P = 0.019) than control group infants. The percentage of parents intending to vaccinate their infants was higher in the intervention group (77% vs. 52%; P < 0.01). Improvements in scores for basic knowledge (mean [SD]: 5.5 [3.6] vs. 3.0 [3.8], range: 10–30; P < 0.001), advanced knowledge (mean [SD]: 5.1 [2.4] vs. 2.8 [2.5], range: 5–15; P < 0.001), and health literacy regarding immunization (mean [SD]: 0.5 [0.8] vs. 0.2 [0.6], range: 1–5; P < 0.01) were higher in the intervention group. The rate of decision making by both parents (68% vs. 52%; P < 0.05) was higher in the intervention group.

Conclusions

Our findings confirmed the program’s effectiveness. The intervention improved immunization rates, the percentage of parents intending to vaccinate their infants and knowledge scores. Interventions which directly and indirectly involved fathers in shared decision-making on whether to immunize their child were effective, as were individualized interventions that provided parents with access to up-to-date information.

Trial registration

UMIN000012575. Registered 14 December 2013 (The study was prospectively registered).

Addressing personal parental values in decisions about childhood vaccination: Measure development

OBJECTIVE

Evidence-based strategies to address vaccine hesitancy are lacking. Personal values are a measurable psychological construct that could be used to deliver personalized messages to influence vaccine hesitancy and behavior. Our objectives were to develop a valid, reliable self-report survey instrument to measure vaccine values based on the Schwartz theory of basic human values, and to test the hypothesis that vaccine values are distinct from vaccine attitudes and are related to vaccine hesitancy and behavior.

METHODS

Parental Vaccine Values (PVV) scale items were generated using formative qualitative research and expert input, yielding 24 items for testing. 295 parents of children aged 14-30 months completed a self-report survey with measures of Schwartz's global values, the PVV, vaccine attitudes, and vaccine hesitancy. Factor analysis was used to determine vaccine values factor structure. Associations between vaccine values, vaccine attitudes, vaccine hesitancy, and vaccination behavior were assessed using linear and logistic regression models. Late vaccination was assessed from electronic medical records.

RESULTS

A six-factor structure for vaccine values was determined with good fit (RMSEA = 0.07, Bentler's CFI = 0.91) with subscales for Conformity, Universalism, Tradition, Self-Direction, Security- Disease Prevention, and Security- Vaccine Risk. Vaccine values were moderately associated with Schwartz global values and vaccine attitudes, indicating discriminant validity from these constructs. Multivariable linear regression showed vaccine hesitancy was associated with vaccine values Conformity (partial R² = 0.10) and Universalism (0.04) and vaccine attitudes Vaccine Safety (0.52) and Vaccine Benefit (0.16). Multivariable logistic regression showed that late vaccination was associated with vaccine value Self-direction (OR = 1.80, 95% CI: 1.26-2.65) and vaccine attitude of Vaccine Benefit (OR = 0.44, 95% CI: 0.32-0.60).

CONCLUSIONS

The PVV scale had good psychometric properties and appears related to but distinct from Schwartz global values and vaccine attitudes. Vaccine values are associated with vaccine hesitancy and late vaccination and may be useful in tailoring future interventions.

Assessing the methodological quality of systematic reviews of interventions aimed at improving vaccination coverage using AMSTAR and ROBIS checklists

Introduction: Systematic reviews (SRs) are the backbone of evidence-based health care, but no gold standard exists to assess their methodological quality. Although the AMSTAR tool is accepted for analyzing the quality of SRs, the ROBIS instrument was recently developed. This study compared the capacity of both instruments to capture the quality of SRs of interventions for improving vaccination coverage.Methods: We conducted a comprehensive literature search in the Cochrane Library and PubMed. Two reviewers independently screened the search output, assessed study eligibility, and extracted data from eligible SRs; resolving differences through consensus. We conducted Principal Component Analysis (PCA) in Stata 14 to determine similarities and differences between AMSTAR and ROBIS.Results: A total of 2322 records were identified through the search and 75 full-text publications were assessed for eligibility, of which 57 met inclusion criteria. Using AMSTAR, we found 32%, 60% and 9% of SRs to have high, moderate and low quality, respectively. With ROBIS, we judged 74%, 14% and 12% of SRs to have low, unclear and high risk of bias. PCA showed that SRs with low risk of bias in ROBIS clustered together with SRs having high-quality in AMSTAR, and SRs with high risk of bias in ROBIS clustered with low-quality SRs in AMSTAR.Conclusions: Our findings suggest that there is an association between methodological quality and risk of bias in SRs of interventions focused on improving vaccination coverage. Therefore, either AMSTAR or ROBIS checklists can be used to evaluate methodological quality of SRs in vaccinology.

Improving the vaccination status of liver transplant patients: Effectiveness of personally addressing patients and written recommendations to family physicians after 3 years

Background

After documenting insufficient vaccinations in 444 liver transplant (LT) patients, we investigated the effects of a combined strategy (addressing both patients and primary care physicians) on immunization prevalences after a 3‐year follow‐up.

Methods

The primary care physicians of all adult LT patients from a university center received a written recommendation addressing immunization needs. Patients were asked for their vaccination documents by phone. Changes in immunization rates for vaccine‐preventable diseases after the intervention were calculated based on patients’ immunization documents from 2014‐2016.

Results

The study cohort consisted of 401 patients. Prevalence rates for all vaccinations improved during the intervention period compared to the baseline study: tetanus from 88.3% to 92.8%, diphtheria from 80.0% to 89.0%, hepatitis A from 50.1% to 60.8%, hepatitis B from 66.3% to 77.1%, and pneumococci from 62.8% to 76.3%. The influenza vaccination rate improved, but remained at a low level before (2010:13%, 2011:11.5%, 2012:19%) and during the intervention (2014:27.4%, 2015:24.4%, 2016:23.2%). Despite these vaccinations, the prevalence rates of the quality indicators standard vaccinations completed (2013:17.2%; 2016:21.2%), indicated vaccinations completed (2013:2.7%, 2016:4.5%), and all vaccinations completed (2013:1%; 2016 1.5%) improved only slightly.

Conclusions

Our results demonstrated that intensified communication by written information to the primary care physician and phone calls to the patients improved the number of vaccinations. Nonetheless, a potential for further improvement persists, especially with regard to annual influenza vaccinations.

Reporting quality of systematic reviews of interventions aimed at improving vaccination coverage: compliance with PRISMA guidelines

Systematic reviews have become increasingly important for informing clinical practice and policy; however, little is known about the reporting characteristics and quality of SRs of interventions to improve immunization coverage in different settings. The aim of this study was to assess the reporting quality of systematic reviews of interventions aimed at improving vaccination coverage using the recommended Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guideline.PubMed and Cochrane Library were searched to identify SRs of interventions to improve immunization coverage, indexed up to May 2016. Two authors independently screened the search output, assessed study eligibility, and extracted data from eligible SRs using a 27-item data collection form derived from PRISMA. Discrepancies in reviews assessments were resolved by discussion and consensus.A total of 57 reviews were included in this study with a mean percentage of applicable PRISMA items that were met across all studies of 66% (range 19-100%) and median compliance of 70%. 39 out of the 57 reviews were published after the release of the PRISMA statement in 2009. Highest compliance was observed in items related to the "description of rational", "description of eligibility criteria", "synthesis of results" and "provision of a general interpretation of the results" (items #3, #6, #14 and #26, respectively). Compliance was poorest in the items "describing summary of evidence" (item 24, 19%), "describing indication of review protocol and registration" (item 5, 26%) and "describing results of risk of bias across studies (item 22, 33%).The overall reporting quality of systematic reviews of interventions to improve vaccination coverage requires significant improvement. There remains a need for additional research targeted at addressing potential barriers to compliance and strategies to improve compliance with PRISMA guideline.

Rotavirus Infection and Vaccination: Knowledge, Beliefs, and Behaviors among Parents in Italy

This study was designed to investigate the knowledge, beliefs, and behaviors about rotavirus infection and its vaccination in a sample of parents in Naples, Italy. The survey was conducted between June and December 2018 among parents of children aged 3 months to 3 years. A total of 40.7% of the study subjects declared that they had heard about rotavirus infection and 60.8% and 59.2% were aware about the vaccination and of its availability in Italy. Parents with a child aged <1 year and those who reported the physicians as source of information were more likely to have heard about rotavirus infection and to know that the vaccination is available in Italy. More than half (56.4%) were worried that their children could have a rotavirus gastroenteritis and this was most likely to occur in those who have heard about rotavirus infection. Only 15.3% declared that they had immunized their children against rotavirus infection. Parents who considered it dangerous for their children to contract the rotavirus gastroenteritis, those who considered the rotavirus vaccine useful, and those who had received information by physicians were more likely to have vaccinated their children against the infection. More than half of the parents who did not immunize their children expressed their willingness to vaccinate them. Developing and implementing additional public education programs are needed for better knowledge toward rotavirus infection and vaccination and a high coverage among parents.

The determinants of vaccination in a semi-rural area of Vientiane City, Lao People's Democratic Republic: a qualitative study

Background

Immunisation is a cost-effective and highly efficacious public health intervention, saving over 20 million lives in the last two decades due to decreases in childhood bacterial infections. In the Lao People’s Democratic Republic, significant gaps in childhood immunisation coverage rates remain, which are a cause for concern and a barrier to the country reaching its Sustainable Development Goal targets for child health. Efforts to increase coverage have had limited success, with widening inequities being observed between urban and remote and rural areas.

Methods

The objectives of this study were two-fold; firstly, to describe the knowledge, attitudes and practices of mothers regarding their children’s immunisation status; and, secondly, to identify individual and health system determinants of access to immunisation in five rural villages within a rural district in Lao People’s Democratic Republic. This qualitative research used observation and interviews with healthcare workers (n = 10) and mothers (n = 10) with at least one child aged 12–23 months.

Results

The study identified several health system barriers that lower community demand for immunisation. These included the use of multiple providers, inconsistent record keeping and an inadequate health information system. At the individual and household level, there was a lack of understanding of the role of immunisation and the role of the different services provided.

Conclusions

The study suggests that increasing immunisation coverage in Lao People’s Democratic Republic requires clearer immunisation pathways, an integrated or unified information recording system across the different levels of the health system, and strategies to increase demand, including increasing individual and household understanding of the role of immunisation in child health.

Electronic supplementary material

The online version of this article (10.1186/s12961-018-0407-9) contains supplementary material, which is available to authorized users.

Impact of a vaccination promotion intervention using motivational interview techniques on long-term vaccine coverage: the PromoVac strategy

BACKGROUND

Delayed vaccinations at 2, 4, and 6 months are associated with a higher probability of delayed age-appropriate vaccination during childhood. This study aimed to assess the effectiveness of an information session on immunization during infancy.

METHODS

An individual educational information session with motivational interview techniques for immunization of infants was conducted (experimental group) or not conducted (control group) during postpartum stay in a quasi-experimental cohort study. Immunization data were collected from the Eastern Townships Public Health registry at 3, 5, 7, 13, 19, and 24 months of age. Logistic regressions with repeated measures were performed to assess the intervention's impact. Relative risks (RR) were estimated. A multivariate model was obtained adjusted for confounding factors.

RESULTS

The experimental and control groups included 1140 and 1249 families, respectively. In per protocol analysis, a significant increase in VC of 3.2, 4.9, 7.3, 6.7, 10.6, and 5.1% was observed at 3, 5, 7, 13, 19, and 24 months. Children from experimental group had 9% more chance at a complete vaccination status between 3 and 24 months compared to children from control group (RR (95% CI): 1.09 (1.05-1.13), p < .001). Children with complete vaccination status at 3 months were more likely to have a complete vaccination status at 24 months (82.3 vs. 48.1%, RR (95% CI): 2.72 (2.28-3.24), p < .001). After adjustment, the estimated RR of the intervention's impact was 1.05 (1.02-1.07), p < .001.

CONCLUSIONS

An educational information session about immunization based on motivational interview techniques conducted during postpartum hospitalization could improve immunization during infancy.

A systematic review and meta-analysis of the effects of educating parents on the benefits and schedules of childhood vaccinations in low and middle-income countries

Public health benefits of childhood vaccinations risk being derailed by low vaccination coverage in low and middle-income countries. One reason for the low coverage is poor parental knowledge of the importance of completing vaccination schedules. We therefore assessed the effects on childhood vaccination coverage, of educating parents and other persons assuming the parental role. We prospectively registered the systematic review, published the protocol, and used standard Cochrane methods to collect and synthesise the evidence. We found six eligible randomised trials with 4248 participants. Three trials assessed health-facility based education of mothers on the importance of completing vaccination schedules; immediately after birth and three months later (one study) or during the first vaccination visit (two studies). The other trials assessed community-based education, including information campaigns on the importance of vaccines using audiotaped presentations and leaflet distributions (one study); structured group discussions on benefits and costs of childhood vaccination and local action plans for improving vaccine uptake (one study); and home-based information sessions using graphic cards showing benefits and costs of childhood vaccinations and location of vaccination centres (one study). Combining the data shows that these interventions lead to substantial improvements in childhood vaccination coverage (relative increase 36%, 95% confidence interval 14% to 62%). There was no difference between the effects of community-based and facility-based education. Therefore, education in communities and health facilities on the importance of childhood vaccinations should be integrated into all vaccination programmes in low and middle-income countries; accompanied by robust monitoring of impacts and use of data for action.

Research priorities in health communication and participation: international survey of consumers and other stakeholders

OBJECTIVE

To identify research priorities of consumers and other stakeholders to inform Cochrane Reviews in 'health communication and participation' (including such concepts as patient experience, shared decision-making and health literacy).

SETTING

International.

PARTICIPANTS

We included anyone with an interest in health communication and participation. Up to 151 participants (18-80 years; 117 female) across 12 countries took part, including 48 consumers (patients, carers, consumer representatives) and 75 professionals (health professionals, policymakers, researchers) (plus 25 people who identified as both).

DESIGN

Survey.

METHODS

We invited people to submit their research ideas via an online survey open for 4 weeks. Using inductive thematic analysis, we generated priority research topics, then classified these into broader themes.

RESULTS

Participants submitted 200 research ideas, which we grouped into 21 priority topics. Key research priorities included: insufficient consumer involvement in research (19 responses), 'official' health information is contradictory and hard to understand (18 responses), communication/coordination breakdowns in health services (15 responses), health information provision a low priority for health professionals (15 responses), insufficient eliciting of patient preferences (14 responses), health services poorly understand/implement patient-centred care (14 responses), lack of holistic care impacting healthcare quality and safety (13 responses) and inadequate consumer involvement in service design (11 responses). These priorities encompassed acute and community health settings, with implications for policy and research. Priority populations of interest included people from diverse cultural and linguistic backgrounds, carers, and people with low educational attainment, or mental illness. Most frequently suggested interventions focused on training and cultural change activities for health services and health professionals.

CONCLUSIONS

Consumers and other stakeholders want research addressing structural and cultural challenges in health services (eg, lack of holistic, patient-centred, culturally safe care) and building health professionals' communication skills. Solutions should be devised in partnership with consumers, and focus on the needs of vulnerable groups.

Face-to-face interventions for informing or educating parents about early childhood vaccination

BACKGROUND

Early childhood vaccination is an essential global public health practice that saves two to three million lives each year, but many children do not receive all the recommended vaccines. To achieve and maintain appropriate coverage rates, vaccination programmes rely on people having sufficient awareness and acceptance of vaccines.Face-to-face information or educational interventions are widely used to help parents understand why vaccines are important; explain where, how and when to access services; and address hesitancy and concerns about vaccine safety or efficacy. Such interventions are interactive, and can be adapted to target particular populations or identified barriers.This is an update of a review originally published in 2013.

OBJECTIVES

To assess the effects of face-to-face interventions for informing or educating parents about early childhood vaccination on vaccination status and parental knowledge, attitudes and intention to vaccinate.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, Embase, five other databases, and two trial registries (July and August 2017). We screened reference lists of relevant articles, and contacted authors of included studies and experts in the field. We had no language or date restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs evaluating the effects of face-to-face interventions delivered to parents or expectant parents to inform or educate them about early childhood vaccination, compared with control or with another face-to-face intervention. The World Health Organization recommends that children receive all early childhood vaccines, with the exception of human papillomavirus vaccine (HPV), which is delivered to adolescents.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two authors independently reviewed all search results, extracted data and assessed the risk of bias of included studies.

MAIN RESULTS

In this update, we found four new studies, for a total of ten studies. We included seven RCTs and three cluster-RCTs involving a total of 4527 participants, although we were unable to pool the data from one cluster-RCT. Three of the ten studies were conducted in low- or middle- income countries.All included studies compared face-to-face interventions with control. Most studies evaluated the effectiveness of a single intervention session delivered to individual parents. The interventions were an even mix of short (ten minutes or less) and longer sessions (15 minutes to several hours).Overall, elements of the study designs put them at moderate to high risk of bias. All studies but one were at low risk of bias for sequence generation (i.e. used a random number sequence). For allocation concealment (i.e. the person randomising participants was unaware of the study group to which participant would be allocated), three were at high risk and one was judged at unclear risk of bias. Due to the educational nature of the intervention, blinding of participants and personnel was not possible in any studies. The risk of bias due to blinding of outcome assessors was judged as low for four studies. Most studies were at unclear risk of bias for incomplete outcome data and selective reporting. Other potential sources of bias included failure to account for clustering in a cluster-RCT and significant unexplained baseline differences between groups. One cluster-RCT was at high risk for selective recruitment of participants.We judged the certainty of the evidence to be low for the outcomes of children's vaccination status, parents' attitudes or beliefs, intention to vaccinate, adverse effects (e.g. anxiety), and immunisation cost, and moderate for parents' knowledge or understanding. All studies had limitations in design. We downgraded the certainty of the evidence where we judged that studies had problems with randomisation or allocation concealment, or when outcomes were self-reported by participants who knew whether they'd received the intervention or not. We also downgraded the certainty for inconsistency (vaccination status), imprecision (intention to vaccinate and adverse effects), and indirectness (attitudes or beliefs, and cost).Low-certainty evidence from seven studies (3004 participants) suggested that face-to-face interventions to inform or educate parents may improve vaccination status (risk ratio (RR) 1.20, 95% confidence interval (CI) 1.04 to 1.37). Moderate-certainty evidence from four studies (657 participants) found that face-to-face interventions probably slightly improved parent knowledge (standardised mean difference (SMD) 0.19, 95% CI 0.00 to 0.38), and low-certainty evidence from two studies (179 participants) suggested they may slightly improve intention to vaccinate (SMD 0.55, 95% CI 0.24 to 0.85). Low-certainty evidence found the interventions may lead to little or no change in parent attitudes or beliefs about vaccination (SMD 0.03, 95% CI -0.20 to 0.27; three studies, 292 participants), or in parents' anxiety (mean difference (MD) -1.93, 95% CI -7.27 to 3.41; one study, 90 participants). Only one study (365 participants) measured the intervention cost of a case management strategy, reporting that the estimated additional cost per fully immunised child for the intervention was approximately eight times higher than usual care (low-certainty evidence). No included studies reported outcomes associated with parents' experience of the intervention (e.g. satisfaction).

AUTHORS' CONCLUSIONS

There is low- to moderate-certainty evidence suggesting that face-to-face information or education may improve or slightly improve children's vaccination status, parents' knowledge, and parents' intention to vaccinate.Face-to-face interventions may be more effective in populations where lack of awareness or understanding of vaccination is identified as a barrier (e.g. where people are unaware of new or optional vaccines). The effect of the intervention in a population where concerns about vaccines or vaccine hesitancy is the primary barrier is less clear. Reliable and validated scales for measuring more complex outcomes, such as attitudes or beliefs, are necessary in order to improve comparisons of the effects across studies.

Increasing Vaccination: Putting Psychological Science Into Action

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.

UNderstanding uptake of Immunisations in TravellIng aNd Gypsy communities (UNITING): a qualitative interview study

BACKGROUND

Gypsies, Travellers and Roma (referred to as Travellers) are less likely to access health services, including immunisation. To improve immunisation rates, we need to understand what helps and hinders individuals in these communities in taking up immunisations.

AIMS

(1) Investigate the barriers to and facilitators of acceptability and uptake of immunisations among six Traveller communities across four UK cities; and (2) identify possible interventions to increase uptake of immunisations in these Traveller communities that could be tested in a subsequent feasibility study.

METHODS

Three-phase qualitative study underpinned by the social ecological model. Phase 1: interviews with 174 Travellers from six communities: Romanian Roma (Bristol); English Gypsy/Irish Traveller (Bristol); English Gypsy (York); Romanian/Slovakian Roma (Glasgow); Scottish Showpeople (Glasgow); and Irish Traveller (London). Focus on childhood and adult vaccines. Phase 2: interviews with 39 service providers. Data were analysed using the framework approach. Interventions were identified using a modified intervention mapping approach. Phase 3: 51 Travellers and 25 service providers attended workshops and produced a prioritised list of potentially acceptable and feasible interventions.

RESULTS

There were many common accounts of barriers and facilitators across communities, particularly across the English-speaking communities. Scottish Showpeople were the most similar to the general population. Roma communities experienced additional barriers of language and being in a new country. Men, women and service providers described similar barriers and facilitators. There was widespread acceptance of childhood and adult immunisation, with current parents perceived as more positive than their elders. A minority of English-speaking Travellers worried about multiple/combined childhood vaccines, adult flu and whooping cough. Cultural concerns about vaccines offered during pregnancy and about human papillomavirus were most evident in the Bristol English Gypsy/Irish Traveller community. Language, literacy, discrimination, poor school attendance, poverty and housing were identified by Travellers and service providers as barriers for some. Trustful relationships with health professionals were important and continuity of care was valued. A few English-speaking Travellers described problems of booking and attending for immunisation. Service providers tailored their approach to Travellers, particularly the Roma. Funding cuts, NHS reforms and poor monitoring challenged their work. Five 'top-priority' interventions were agreed across communities and service providers to improve the immunisation among Travellers who are housed or settled on an authorised site: (1) cultural competence training for health professionals and frontline staff; (2) identification of Travellers in health records to tailor support and monitor uptake; (3) provision of a named frontline person in general practitioner practices to provide respectful and supportive service; (4) flexible and diverse systems for booking appointments, recall and reminders; and (5) protected funding for health visitors specialising in Traveller health, including immunisation.

LIMITATIONS

No Travellers living on the roadside or on unofficial encampments were interviewed. We should exert caution in generalising to these groups.

FUTURE WORK

To include development, implementation and evaluation of a national policy plan (and practice guidance plan) to promote the uptake of immunisation among Traveller communities.

STUDY REGISTRATION

Current Controlled Trials ISRCTN20019630 and UK Clinical Research Network Portfolio number 15182.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 72. See the NIHR Journals Library website for further project information.

Perceptions and experiences of childhood vaccination communication strategies among caregivers and health workers in Nigeria: A qualitative study

BACKGROUND

Effective vaccination communication with parents is critical in efforts to overcome barriers to childhood vaccination, tackle vaccine hesitancy and improve vaccination coverage. Health workers should be able to provide information to parents and other caregivers and support them in reaching decisions about vaccinating their children. Limited information exists regarding the perceptions of caregivers and health workers on the vaccination communication strategies employed in Nigeria. This study, which forms part of the 'Communicate to vaccinate' (COMMVAC) project, aims to explore the perceptions and experiences of caregivers and health workers in Nigeria on vaccination communication strategies implemented in their settings.

METHODOLOGY

We conducted the study in two States: Bauchi in Northern Nigeria and Cross River in the south. We carried out observations (n = 40), in-depth interviews (n = 14) and focus group discussions (FGDs) (n = 12) amongst 14 purposively selected health workers, two community leaders and 84 caregivers in the two states. We transcribed data verbatim and analysed the data using a framework analysis approach.

RESULTS

Caregivers were informed about vaccination activities through three main sources: health facilities (during health education sessions conducted at antenatal or immunization clinics); media outlets; and announcements (in churches/mosques, communities and markets). Caregivers reported that the information received was very useful. Their preferred sources of information included phone text messages, town announcers, media and church/mosque announcements. Some caregivers perceived the clinic environment, long waiting times and health worker attitudes as barriers to receiving vaccination information.When delivering communication interventions, health workers described issues tied to poor communication skills; poor motivation; and attitudes of community members, including vaccine resistance.

CONCLUSION

Communication about vaccination involves more than the message but is also influenced by the environment and the attitudes of the deliverer and receiver. It is pertinent for health policy makers and programme managers to understand these factors so as to effectively implement communication approaches.

Knowledge, attitudes and opinions towards measles and the MMR vaccine across two NSW cohorts

OBJECTIVE

Although the number of national measles cases has greatly decreased since 1980s, there has been resurgence in disease incidence in recent years. While parental knowledge and attitudes toward both disease and vaccinations are known to influence vaccine uptake, the contribution of these factors toward vaccination rates in NSW populations has not been studied. The aim of this study was to investigate the knowledge and opinions on measles and MMR vaccine in NSW Central and North Coast regions.

METHODS

Parents (n=201) of children <12 years were surveyed with a purpose design survey at public beaches at the Central Coast and community markets at the North Coast.

RESULTS

Eight per cent of respondents reported not immunising their child with MMR vaccine. Most respondents recognised that measles is a highly contagious disease. Non-immunisers were found to be older, had a lower perceived severity of measles, were less likely to agree with the efficacy and safety of the vaccine, and were more likely to have encountered someone who had suffered side-effects of the vaccine.

CONCLUSIONS

There is considerable concern over safety of MMR vaccine among non-immunisers. Implications for public health: Improving confidence in MMR vaccine should be a target of future public health interventions.

Stakeholder perceptions of communication about vaccination in two regions of Cameroon: A qualitative case study

BACKGROUND

Understanding stakeholders' (parents', communities' and health workers') perspectives of communication about childhood vaccination, including their preferences for its format, delivery and content, is an important step towards designing better communication strategies and ensuring more informed parents. Our objectives were to explore stakeholders' views, experiences and preferences for childhood vaccination communication in Cameroon.

METHODS

In 2014, in the Central and North West Regions of Cameron, we gathered qualitative data for our case study using the following methods: semi structured interviews; observations and informal conversations during routine immunization clinics and three rounds of the National Polio Immunization Campaign; document analysis of reports and mass media communications about vaccination; and a survey of parents. We conducted a thematic analysis of the qualitative data to identify themes relating to views, experiences and perceptions of vaccination information and its delivery. Survey data were analysed using simple descriptive statistics.

RESULTS

All of the parents interviewed felt that vaccinating their child was important, and trusted the information provided by health workers. However, many parents wanted more information. Parents did not always feel that they could ask questions during vaccination appointments. All participants felt that health workers and vaccination clinics were important sources of information. Social mobilisation activities such as door-to-door visits and announcements during religious services were important and accepted ways of communicating information, especially during vaccination campaigns. Information communicated through mass media and text messages was also seen as important. In general, stakeholders believed that more consistent messaging about routine vaccination through community channels would be helpful to remind parents of the importance of routine vaccination during ongoing rounds of vaccination campaigns against polio.

CONCLUSIONS

This study confirms that parents regard information about childhood vaccination as important, but that health services need to be organized in ways that prioritize and facilitate communication, particularly about routine vaccination.

Knowledge, Attitudes and Perceptions About Routine Childhood Vaccinations Among Jewish Ultra-Orthodox Mothers Residing in Communities with Low Vaccination Coverage in the Jerusalem District

Background and aims Childhood vaccinations are an important component of primary prevention. Maternal and Child Health (MCH) clinics in Israel provide routine vaccinations without charge. Several vaccine-preventable-diseases outbreaks (measles, mumps) emerged in Jerusalem in the past decade. We aimed to study attitudes and knowledge on vaccinations among mothers, in communities with low immunization coverage. Methods A qualitative study including focus groups and semi-structured interviews. Results Low immunization coverage was defined below the district's mean (age 2 years, 2013) for measles-mumps-rubella-varicella 1st dose (MMR1\MMRV1) and diphtheria-tetanus-pertussis 4th dose (DTaP4), 96 and 89%, respectively. Five communities were included, all were Jewish ultra-orthodox. The mothers' (n = 87) median age was 30 years and median number of children 4. Most mothers (94%) rated vaccinations as the main activity in the MCH clinics with overall positive attitudes. Knowledge about vaccines and vaccination schedule was inadequate. Of vaccines scheduled at ages 0-2 years (n = 13), the mean number mentioned was 3.9 ± 2.8 (median 4, range 0-9). Vaccines mentioned more often were outbreak-related (measles, mumps, polio) and HBV (given to newborns). Concerns about vaccines were obvious, trust issues and religious beliefs were not. Vaccination delay was very common and timeliness was considered insignificant. Practical difficulties in adhering to the recommended schedule prevailed. The vaccinations visits were associated with pain and stress. Overall, there was a sense of self-responsibility accompanied by inability to influence others. Conclusion Investigating maternal knowledge and attitudes on childhood vaccinations provides insights that may assist in planning tailored intervention programs aimed to increase both vaccination coverage and timeliness.

Vaccine decision-making begins in pregnancy: Correlation between vaccine concerns, intentions and maternal vaccination with subsequent childhood vaccine uptake

INTRODUCTION

Maternal and childhood vaccine decision-making begins prenatally. Amongst pregnant Australian women we aimed to ascertain vaccine information received, maternal immunisation uptake and attitudes and concerns regarding childhood vaccination. We also aimed to determine any correlation between a) intentions and concerns regarding childhood vaccination, (b) concerns about pregnancy vaccination, (c) socioeconomic status (SES) and (d) uptake of influenza and pertussis vaccines during pregnancy and routine vaccines during childhood.

METHODS

Women attending public antenatal clinics were recruited in three Australian states. Surveys were completed on iPads. Follow-up phone surveys were done three to six months post delivery, and infant vaccination status obtained via the Australian Childhood Immunisation Register (ACIR).

RESULTS

Between October 2015 and March 2016, 975 (82%) of 1184 mothers consented and 406 (42%) agreed to a follow up survey, post delivery. First-time mothers (445; 49%) had significantly more vaccine concerns in pregnancy and only 73% had made a decision about childhood vaccination compared to 89% of mothers with existing children (p-value<0.001). 66% of mothers reported receiving enough information during pregnancy on childhood vaccination. In the post delivery survey, 46% and 82% of mothers reported receiving pregnancy influenza and pertussis vaccines respectively. The mother's degree of vaccine hesitancy and two attitudinal factors were correlated with vaccine uptake post delivery. There was no association between reported maternal vaccine uptake or SES and childhood vaccine uptake.

CONCLUSION

First time mothers are more vaccine hesitant and undecided about childhood vaccination, and only two thirds of all mothers believed they received enough information during pregnancy. New interventions to improve both education and communication on childhood and maternal vaccines, delivered by midwives and obstetricians in the Australian public hospital system, may reduce vaccine hesitancy for all mothers in pregnancy and post delivery, particularly first-time mothers.

Beyond "Back to Sleep": Ways to Further Reduce the Risk of Sudden Infant Death Syndrome

Sudden infant death syndrome (SIDS) remains the leading cause of postneonatal mortality in the United States, despite reduction in rates of more than 50% since the initiation of the "Back to Sleep" (now called "Safe to Sleep") campaign in 1994. In recent years, the rate of decline in SIDS deaths has plateaued, even with the ongoing educational efforts that promote safe sleep and other risk reduction measures. The 2016 American Academy of Pediatrics guidelines for reducing the risk of SIDS focus heavily on sleep practices, bedding, and location, but also include factors that often receive less attention (ie, prenatal care, maternal smoking, alcohol and drug use, and childhood vaccinations). This review describes these factors that are less often addressed and identifies interventions that have resulted in positive behavioral changes that not only benefit infants, but also promote the health and well-being of their mothers. [Pediatr Ann. 2017;46(8):e284-e290.].

Strategies to increase immunization coverage of tetanus vaccine among women in Sub Saharan Africa: a systematic review

World Health Organization (WHO) estimated in 2013 that 49,000 deaths all over the world were caused by neonatal tetanus. Only as recently as the year 2000, neonatal tetanus was a public health problem in 59 countries, but since then it has been eliminated in 36 of the countries concerned. The objective of this piece of work, therefore, was to investigate which strategies intended to increase demand for vaccination are effective in increasing anti-tetanus vaccination coverage of women in Sub Saharan Africa. We searched the following electronic databases from January 1989 to July 2016: Medline, EMBASE (Excerpta Medica Database), The Cochrane Library, Google Scholar, CINAHL (Cumulative Index to Nursing and Allied Health Literature), WHOLIS (World Health Organization Library Database), LILACS (Latin American and Caribbean Literature on Health Sciences) and contacted experts in the field. There were no restrictions to language or publication status. All study designs that could provide the information we sought were eligible, provided the studies were conducted in sub-Saharan Africa. Critical appraisal of all identified citations was done independently by two authors to establish the possible relevance of the articles for inclusion in the review. Our search strategy yielded 191 records and after assessment for eligibility, 6 papers met the criteria for inclusion. In Ivory Coast, after reorganization, health workers said they were satisfied with the work environment and the care provided in 91% and 96% of cases, respectively. In Kenya, the main factors contributing to having sufficiently immunized part of the population against tetanus are lower birth order, higher household wealth index, women's employment, making joint health-related decisions with a partner, and higher number of antenatal care visits. Particularly in Ethiopia, compared with other member countries, the size of the unimmunized population, reporting quality, fragileness of the health system, resource limitation, and others deserve further concerted attention. In Nigeria, the prevalence of missed opportunities was 66%. The factors responsible for missed opportunities were; poor history taking, lack of knowledge of the current immunization schedule, dependence on physician referral for immunization and inefficient immunization records keeping system. In Nigeria, socio-logistic variables found to be important in Expanded Programme on Immunization implementations included scheduling, health staff attitude, intersectoral collaboration, and health education. Lack of community participation was also found to be a crucial constraining factor. There are many challenges to increase immunization coverage of tetanus vaccine for women. So far very few interventions addressing these challenges have been evaluated scientifically. Community mobilization interventions to change or impact beliefs and attitudes of women are absolutely needed. Additionally, improving accessibility, affordability, availability and accommodation of vaccination service venues will make them more attractive.

Research on subgroups is not research on equity attributes: Evidence from an overview of systematic reviews on vaccination

BACKGROUND

Equity remains a priority in the international health development agenda. However, major inequities in vaccination coverage jeopardise the achievement of the Sustainable Development Goals. We aim at comprehensively describing how research has addressed equity issues related to vaccination.

METHODS

We carried out an overview of systematic reviews (SRs) that explicitly explored the effects of interventions to improve vaccination in any context; for any vaccine and, in any language. We followed standard research synthesis methods to systematically search for SR, assess them for inclusion and extracting relevant data, particularly on vaccination related outcomes. To gather evidence on equity issues addressed in the SR, we used the PROGRESS-plus framework.

FINDINGS

Our search obtained 2,003 hits which resulted in 54 included SRs, published between 1994 and 2014. The quality of SRs was generally poor, with less than half complying with most of the quality criteria. Reported vaccines included, by order of frequency, influenza and Expanded Programme on Immunisation vaccines. The types of interventions more frequently reported were related to vaccination delivery strategies, financial support and information, education and communication. Most of the SRs suggested effects favouring intervention groups as opposed to comparison groups. The most frequently reported equity attribute was 'place of residence' and the least reported equity attributes were sexual orientation and religion. Very few estimates of effects actually measured differences or changes between groups having those attributes and all of them referred to the place of residence. No data was found about reducing equity gaps for vulnerable groups or minorities, or attributes such as sexual orientation, education or specific religious groups.

CONCLUSIONS

Although research on vulnerable populations as a subgroup is abundant, it fails to report on the interventions that will actually reduce inequities and consider how redistribution of health care resources could shrink the gap between the privileged and most vulnerable groups including minorities. Research, if aiming at being responsive to global health policy trends, needs to report not only on specific attributes but also on how a better redistribution of health care resources could contribute to alleviating the unjust situation of the most vulnerable populations.

The comprehensive 'Communicate to Vaccinate' taxonomy of communication interventions for childhood vaccination in routine and campaign contexts

BACKGROUND

Communication can be used to generate demand for vaccination or address vaccine hesitancy, and is crucial to successful childhood vaccination programmes. Research efforts have primarily focused on communication for routine vaccination. However, vaccination campaigns, particularly in low- or middle-income countries (LMICs), also use communication in diverse ways. Without a comprehensive framework integrating communication interventions from routine and campaign contexts, it is not possible to conceptualise the full range of possible vaccination communication interventions. Therefore, vaccine programme managers may be unaware of potential communication options and researchers may not focus on building evidence for interventions used in practice. In this paper, we broaden the scope of our existing taxonomy of communication interventions for routine vaccination to include communication used in campaigns, and integrate these into a comprehensive taxonomy of vaccination communication interventions.

METHODS

Building on our taxonomy of communication for routine vaccination, we identified communication interventions used in vaccination campaigns through a targeted literature search; observation of vaccination activities in Cameroon, Mozambique and Nigeria; and stakeholder consultations. We added these interventions to descriptions of routine vaccination communication and categorised the interventions according to their intended purposes, building from an earlier taxonomy of communication related to routine vaccination.

RESULTS

The comprehensive taxonomy groups communication used in campaigns and routine childhood vaccination into seven purpose categories: 'Inform or Educate'; 'Remind or Recall'; 'Enhance Community Ownership'; 'Teach Skills'; 'Provide Support'; 'Facilitate Decision Making' and 'Enable Communication'. Consultations with LMIC stakeholders and experts informed the taxonomy's definitions and structure and established its potential uses.

CONCLUSIONS

This taxonomy provides a standardised way to think and speak about vaccination communication. It is categorised by purpose to help conceptualise communication interventions as potential solutions to address needs or problems. It can be utilised by programme planners, implementers, researchers and funders to see the range of communication interventions used in practice, facilitate evidence synthesis and identify evidence gaps.

The Immunity Community: A Community Engagement Strategy for Reducing Vaccine Hesitancy

Parental concerns about vaccine safety have grown in the United States and abroad, resulting in delayed or skipped immunizations (often called “vaccine hesitancy”). To address vaccine hesitancy in Washington State, a public–private partnership of health organizations implemented and evaluated a 3-year community intervention, called the “Immunity Community.” The intervention mobilized parents who value immunization and provided them with tools to engage in positive dialogue about immunizations in their communities. The evaluation used qualitative and quantitative methods, including focus groups, interviews, and pre and post online surveys of parents, to assess perceptions about and reactions to the intervention, assess facilitators and barriers to success, and track outcomes including parental knowledge and attitudes. The program successfully engaged parent volunteers to be immunization advocates. Surveys of parents in the intervention communities showed statistically significant improvements in vaccine-related attitudes: The percentage concerned about other parents not vaccinating their children increased from 81.2% to 88.6%, and the percentage reporting themselves as “vaccine-hesitant” decreased from 22.6% to 14.0%. There were not statistically significant changes in parental behaviors. This study demonstrates the promise of using parent advocates as part of a community-based approach to reduce vaccine hesitancy.

Provider-parent Communication When Discussing Vaccines: A Systematic Review

PROBLEM

Expert literature on communication practices with vaccine hesitant parents posits that a non-confrontational/participatory discussion with the parent would be the best approach to improve compliance. A prior literature review found limited evidence to recommend any particular face to face intervention other than to incorporate communication about vaccination effectiveness during an encounter. Hence, a systematic review was performed in an attempt to determine the most efficacious communication practices to use with parents with vaccination concerns.

ELIGIBILITY CRITERIA

Quantitative and qualitative studies written in English that assessed the communication framework/style of the provider-parent interaction and studies where provider communication was listed as an intervention were reviewed.

SAMPLE

Nine articles were included in the sample.

RESULTS

The majority of the studies were descriptive and qualitative in nature with only one randomized controlled trial. Five of the 9 studies utilized a descriptive cross-sectional design. Two main themes included message types recommended or given by the provider and message types that were requested by the parent.

CONCLUSIONS

Overall, findings showed that there is currently not enough information to definitively state the type of provider-parent communication style that should be employed to affect the parents' vaccination viewpoint. However, recurring themes of trust in the provider and a personalized provider-parent interaction were evident, which promotes a participatory type of interaction.

IMPLICATIONS

The literature indirectly supports providers engaging with vaccine hesitant parents in a more individualized, participatory format, though higher quality and more rigorous studies that focus specifically on provider-parent communication practices are needed.

Parents' and informal caregivers' views and experiences of communication about routine childhood vaccination: a synthesis of qualitative evidence

BACKGROUND

Childhood vaccination is an effective way to prevent serious childhood illnesses, but many children do not receive all the recommended vaccines. There are various reasons for this; some parents lack access because of poor quality health services, long distances or lack of money. Other parents may not trust vaccines or the healthcare workers who provide them, or they may not see the need for vaccination due to a lack of information or misinformation about how vaccinations work and the diseases they can prevent.Communication with parents about childhood vaccinations is one way of addressing these issues. Communication can take place at healthcare facilities, at home or in the community. Communication can be two-way, for example face-to-face discussions between parents and healthcare providers, or one-way, for instance via text messages, posters or radio programmes. Some types of communication enable parents to actively discuss vaccines and their benefits and harms, as well as diseases they can prevent. Other communication types simply give information about vaccination issues or when and where vaccines are available. People involved in vaccine programmes need to understand how parents experience different types of communication about vaccination and how this influences their decision to vaccinate.

OBJECTIVES

The specific objectives of the review were to identify, appraise and synthesise qualitative studies exploring: parents' and informal caregivers' views and experiences regarding communication about childhood vaccinations and the manner in which it is communicated; and the influence that vaccination communication has on parents' and informal caregivers' decisions regarding childhood vaccination.

SEARCH METHODS

We searched MEDLINE (OvidSP), MEDLINE In-process and Other Non-Index Citations (Ovid SP), Embase (Ovid), CINAHL (EbscoHOST), and Anthropology Plus (EbscoHost) databases for eligible studies from inception to 30 August 2016. We developed search strategies for each database, using guidelines developed by the Cochrane Qualitative Research Methods Group for searching for qualitative evidence as well as modified versions of the search developed for three related reviews of effectiveness. There were no date or geographic restrictions for the search.

SELECTION CRITERIA

We included studies that utilised qualitative methods for data collection and analysis; focused on the views and experiences of parents and informal caregivers regarding information about vaccination for children aged up to six years; and were from any setting globally where information about childhood vaccinations was communicated or distributed.

DATA COLLECTION AND ANALYSIS

We used maximum variation purposive sampling for data synthesis, using a three-step sampling frame. We conducted a thematic analysis using a constant comparison strategy for data extraction and synthesis. We assessed our confidence in the findings using the GRADE-CERQual approach. High confidence suggests that it is highly likely that the review finding is a reasonable representation of the phenomenon of interest, while very low confidence indicates that it is not clear whether the review finding is a reasonable representation of it. Using a matrix model, we then integrated our findings with those from other Cochrane reviews that assessed the effects of different communication strategies on parents' knowledge, attitudes and behaviour about childhood vaccination.

MAIN RESULTS

We included 38 studies, mostly from high-income countries, many of which explored mothers' perceptions of vaccine communication. Some focused on the MMR (measles, mumps, rubella) vaccine.In general, parents wanted more information than they were getting (high confidence in the evidence). Lack of information led to worry and regret about vaccination decisions among some parents (moderate confidence).Parents wanted balanced information about vaccination benefits and harms (high confidence), presented clearly and simply (moderate confidence) and tailored to their situation (low confidence in the evidence). Parents wanted vaccination information to be available at a wider variety of locations, including outside health services (low confidence) and in good time before each vaccination appointment (moderate confidence).Parents viewed health workers as an important source of information and had specific expectations of their interactions with them (high confidence). Poor communication and negative relationships with health workers sometimes impacted on vaccination decisions (moderate confidence).Parents generally found it difficult to know which vaccination information source to trust and challenging to find information they felt was unbiased and balanced (high confidence).The amount of information parents wanted and the sources they felt could be trusted appeared to be linked to acceptance of vaccination, with parents who were more hesitant wanting more information (low to moderate confidence).Our synthesis and comparison of the qualitative evidence shows that most of the trial interventions addressed at least one or two key aspects of communication, including the provision of information prior to the vaccination appointment and tailoring information to parents' needs. None of the interventions appeared to respond to negative media stories or address parental perceptions of health worker motives.

AUTHORS' CONCLUSIONS

We have high or moderate confidence in the evidence contributing to several review findings. Further research, especially in rural and low- to middle-income country settings, could strengthen evidence for the findings where we had low or very low confidence. Planners should consider the timing for making vaccination information available to parents, the settings where information is available, the provision of impartial and clear information tailored to parental needs, and parents' perceptions of health workers and the information provided.

Interventions to reduce inequalities in vaccine uptake in children and adolescents aged <19 years: a systematic review

BACKGROUND

In high-income countries, substantial differences exist in vaccine uptake relating to socioeconomic status, gender, ethnic group, geographic location and religious belief. This paper updates a 2009 systematic review on effective interventions to decrease vaccine uptake inequalities in light of new technologies applied to vaccination and new vaccine programmes (eg, human papillomavirus in adolescents).

METHODS

We searched MEDLINE, Embase, ASSIA, The Campbell Collaboration, CINAHL, The Cochrane Database of Systematic Reviews, Eppi Centre, Eric and PsychINFO for intervention, cohort or ecological studies conducted at primary/community care level in children and young people from birth to 19 years in OECD countries, with vaccine uptake or coverage as outcomes, published between 2008 and 2015.

RESULTS

The 41 included studies evaluated complex multicomponent interventions (n=16), reminder/recall systems (n=18), outreach programmes (n=3) or computer-based interventions (n=2). Complex, locally designed interventions demonstrated the best evidence for effectiveness in reducing inequalities in deprived, urban, ethnically diverse communities. There is some evidence that postal and telephone reminders are effective, however, evidence remains mixed for text-message reminders, although these may be more effective in adolescents. Interventions that escalated in intensity appeared particularly effective. Computer-based interventions were not effective. Few studies targeted an inequality specifically, although several reported differential effects by the ethnic group.

CONCLUSIONS

Locally designed, multicomponent interventions should be used in urban, ethnically diverse, deprived populations. Some evidence is emerging for text-message reminders, particularly in adolescents. Further research should be conducted in the UK and Europe with a focus on reducing specific inequalities.

Cancer Prevention: HPV Vaccination

OBJECTIVES

To provide an overview of human papillomavirus (HPV) vaccination as cancer prevention with current strategies that nurses can use to help patients and parents overcome barriers to HPV vaccination.

DATA SOURCES

Peer-reviewed literature, presentation abstracts, and current immunization recommendations from the Advisory Council on Immunization Practice.

CONCLUSION

Nurses can help prevent cancer by encouraging HPV vaccination during routine immunization and make HPV vaccination normal and routine.

IMPLICATIONS FOR NURSING PRACTICE

A vaccine to reduce/eliminate HPV-related cancers enables nurses' at all educational levels to advocate for cancer prevention through initiation and completion of the HPV vaccine series.

Interventions for improving coverage of childhood immunisation in low- and middle-income countries

BACKGROUND

Immunisation is a powerful public health strategy for improving child survival, not only by directly combating key diseases that kill children but also by providing a platform for other health services. However, each year millions of children worldwide, mostly from low- and middle-income countries (LMICs), do not receive the full series of vaccines on their national routine immunisation schedule. This is an update of the Cochrane review published in 2011 and focuses on interventions for improving childhood immunisation coverage in LMICs.

OBJECTIVES

To evaluate the effectiveness of intervention strategies to boost and sustain high childhood immunisation coverage in LMICs.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2016, Issue 4, part of The Cochrane Library. www.cochranelibrary.com, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 12 May 2016); MEDLINE In-Process and Other Non-Indexed Citations, MEDLINE Daily and MEDLINE 1946 to Present, OvidSP (searched 12 May 2016); CINAHL 1981 to present, EbscoHost (searched 12 May 2016); Embase 1980 to 2014 Week 34, OvidSP (searched 2 September 2014); LILACS, VHL (searched 2 September 2014); Sociological Abstracts 1952 - current, ProQuest (searched 2 September 2014). We did a citation search for all included studies in Science Citation Index and Social Sciences Citation Index, 1975 to present; Emerging Sources Citation Index 2015 to present, ISI Web of Science (searched 2 July 2016). We also searched the two Trials Registries: ICTRP and ClinicalTrials.gov (searched 5 July 2016) SELECTION CRITERIA: Eligible studies were randomised controlled trials (RCT), non-RCTs, controlled before-after studies, and interrupted time series conducted in LMICs involving children aged from birth to four years, caregivers, and healthcare providers.

DATA COLLECTION AND ANALYSIS

We independently screened the search output, reviewed full texts of potentially eligible articles, assessed risk of bias, and extracted data in duplicate; resolving discrepancies by consensus. We then conducted random-effects meta-analyses and used GRADE to assess the certainty of evidence.

MAIN RESULTS

Fourteen studies (10 cluster RCTs and four individual RCTs) met our inclusion criteria. These were conducted in Georgia (one study), Ghana (one study), Honduras (one study), India (two studies), Mali (one study), Mexico (one study), Nicaragua (one study), Nepal (one study), Pakistan (four studies), and Zimbabwe (one study). One study had an unclear risk of bias, and 13 had high risk of bias. The interventions evaluated in the studies included community-based health education (three studies), facility-based health education (three studies), household incentives (three studies), regular immunisation outreach sessions (one study), home visits (one study), supportive supervision (one study), information campaigns (one study), and integration of immunisation services with intermittent preventive treatment of malaria (one study).We found moderate-certainty evidence that health education at village meetings or at home probably improves coverage with three doses of diphtheria-tetanus-pertussis vaccines (DTP3: risk ratio (RR) 1.68, 95% confidence interval (CI) 1.09 to 2.59). We also found low-certainty evidence that facility-based health education plus redesigned vaccination reminder cards may improve DTP3 coverage (RR 1.50, 95% CI 1.21 to 1.87). Household monetary incentives may have little or no effect on full immunisation coverage (RR 1.05, 95% CI 0.90 to 1.23, low-certainty evidence). Regular immunisation outreach may improve full immunisation coverage (RR 3.09, 95% CI 1.69 to 5.67, low-certainty evidence) which may substantially improve if combined with household incentives (RR 6.66, 95% CI 3.93 to 11.28, low-certainty evidence). Home visits to identify non-vaccinated children and refer them to health clinics may improve uptake of three doses of oral polio vaccine (RR 1.22, 95% CI 1.07 to 1.39, low-certainty evidence). There was low-certainty evidence that integration of immunisation with other services may improve DTP3 coverage (RR 1.92, 95% CI 1.42 to 2.59).

AUTHORS' CONCLUSIONS

Providing parents and other community members with information on immunisation, health education at facilities in combination with redesigned immunisation reminder cards, regular immunisation outreach with and without household incentives, home visits, and integration of immunisation with other services may improve childhood immunisation coverage in LMIC. Most of the evidence was of low certainty, which implies a high likelihood that the true effect of the interventions will be substantially different. There is thus a need for further well-conducted RCTs to assess the effects of interventions for improving childhood immunisation coverage in LMICs.

Implications for public health research of models and theories of disability: a scoping study and evidence synthesis

Background

Public health interventions that are effective in the general population are often assumed to apply to people with impairments. However, the evidence to support this is limited and hence there is a need for public health research to take a more explicit account of disability and the perspectives of people with impairments.

Objectives

(1) To examine the literature on theories and models of disability; (2) to assess whether or not, and how, intervention studies of effectiveness could incorporate more inclusive approaches that are consistent with these theories and models; and (3) to use the findings to draw out implications for improving evaluative study designs and evidence-based practice.

Review methods

The project is a scoping review of the literature. The first stage examines theories and models of disability and reflects on possible connections between theories of disability and public health paradigms. This discussion is used to develop an ethical–empirical decision aid/checklist, informed by a human rights approach to disability and ecological approaches to public health. We apply this decision aid in the second stage of the review to evaluate the extent to which the 30 generic public health reviews of interventions and the 30 disability-specific public health interventions include the diverse experiences of disability. Five deliberation panels were also organised to further refine the decision aid: one with health-care professionals and four with politically and socially active disabled people.

Results

The evidence from the review indicated that there has been limited public health engagement with theories and models of disability. Outcome measures were often insensitive to the experiences of disability. Even when disabled people were included, studies rarely engaged with their experiences in any meaningful way. More inclusive research should reflect how people live and ‘flourish’ with disability.

Limitations

The scoping review provides a broad appraisal of a particular field. It generates ideas for future practice rather than a definite framework for action.

Conclusions

Our ethical–empirical decision aid offers a critical framework with which to evaluate current research practice. It also offers a resource for promoting more ethical and evidence-based public health research that is methodologically robust while being sensitive to the experiences of disability.

Future work

Developing more inclusive research and interventions that avoid conceptualising disability as either a ‘burden’ or ‘problem’ is an important starting point. This includes exploring ways of refining and validating current common outcome measures to ensure that they capture a diverse range of disabling experiences, as well as generating evidence on meaningful ways of engaging a broad range of disabled children and adults in the research process.

Funding

The National Institute for Health Research Public Health Research programme.

Self-reported prenatal influenza vaccination and early childhood vaccine series completion

BACKGROUND

No studies have examined associations between prenatal vaccination and childhood vaccination. Mothers who refuse influenza vaccinations during pregnancy report similar attitudes and beliefs to those who refuse vaccinations for their children. The objective of this study was to examine the association between self-reported prenatal influenza vaccination and early childhood vaccination.

METHODS

A retrospective cohort study was conducted with existing surveillance data from 4022 mothers who responded to the 2009-2011 Minnesota Pregnancy Risk Assessment Monitoring System survey and child vaccination records from the Minnesota Immunization Information Connection database. The childhood vaccine series outcome included the following vaccines: diphtheria, tetanus, and pertussis; poliovirus; measles, mumps, and rubella; Haemophilus influenzae type b (Hib); hepatitis B; varicella; and pneumococcal conjugate. To evaluate the association between self-reported prenatal influenza vaccination and early childhood vaccination, unadjusted and adjusted logistic regression was used to estimate log odds for childhood vaccination status, while margins post-estimation commands were used to obtain predicted probabilities and risk differences.

RESULTS

Vaccine series completion was 10.86% higher (95% confidence interval (CI) 7.33%-14.40%, adjusted and weighted model) in children of mothers who had a prenatal influenza vaccine compared to those who did not. For individual vaccines in the recommended series, risk differences ranged from 7.83% (95% CI 5.37%, 10.30%) for the Hib vaccine to 10.06% (95% CI 7.29%, 12.83%) for the hepatitis B vaccine.

CONCLUSION

Self-reported prenatal influenza vaccination was associated with increased early childhood vaccination. More research is needed to confirm these results and identify potential intervention strategies.

Communication strategies to promote the uptake of childhood vaccination in Nigeria: a systematic map

BACKGROUND

Effective communication is a critical component in ensuring that children are fully vaccinated. Although numerous communication interventions have been proposed and implemented in various parts of Nigeria, the range of communication strategies used has not yet been mapped systematically. This study forms part of the 'Communicate to vaccinate' (COMMVAC) project, an initiative aimed at building research evidence for improving communication with parents and communities about childhood vaccinations in low- and middle-income countries.

OBJECTIVE

This study aims to: 1) identify the communication strategies used in two states in Nigeria; 2) map these strategies against the existing COMMVAC taxonomy, a global taxonomy of vaccination communication interventions; 3) create a specific Nigerian country map of interventions organised by purpose and target; and 4) analyse gaps between the COMMVAC taxonomy and the Nigerian map.

DESIGN

We conducted the study in two Nigerian states: Bauchi State in Northern Nigeria and Cross River State in Southern Nigeria. We identified vaccination communication interventions through interviews carried out among purposively selected stakeholders in the health services and relevant agencies involved in vaccination information delivery; through observations and through relevant documents. We used the COMMVAC taxonomy to organise the interventions we identified based on the intended purpose of the communication and the group to which the intervention was targeted.

RESULTS

The Nigerian map revealed that most of the communication strategies identified aimed to inform and educate and remind or recall. Few aimed to teach skills, enhance community ownership, and enable communication. We did not identify any intervention that aimed to provide support or facilitate decision-making. Many interventions had more than one purpose. The main targets for most interventions were caregivers and community members, with few interventions directed at health workers. Most interventions identified were used in the context of campaigns rather than routine immunisation programmes.

CONCLUSIONS

The identification and development of the Nigerian vaccination communication interventions map could assist programme managers to identify gaps in vaccination communication. The map may be a useful tool as part of efforts to address vaccine hesitancy and improve vaccination coverage in Nigeria and similar settings.

Mapping how information about childhood vaccination is communicated in two regions of Cameroon: What is done and where are the gaps?

Background

The ‘Communicate to vaccinate’ (COMMVAC) project builds research evidence for improving communication with parents and communities about childhood vaccinations in low- and middle-income countries. Understanding and mapping the range of vaccination communication strategies used in different settings is an important component of this work. In this part of the COMMVAC project, our objectives were: (1) to identify the vaccination communication interventions used in two regions of Cameroon; (2) to apply the COMMVAC taxonomy, a global taxonomy of vaccination communication interventions, to these communication interventions to help us classify these interventions, including their purposes and target audiences; and identify whether gaps in purpose or target audiences exist; (3) to assess the COMMVAC taxonomy as a research tool for data collection and analysis.

Methods

We used the following qualitative methods to identify communication strategies in the Central and North West Regions of Cameroon in the first half of 2014: interviews with program managers, non-governmental organizations, vaccinators, parents and community members; observations and informal conversations during routine immunization clinics and three rounds of the National Polio Immunization Campaign; and document analysis of reports and mass media communications about vaccination. A survey of parents and caregivers was also done. We organised the strategies using the COMMVAC taxonomy and produced a map of Cameroon-specific interventions, which we presented to local stakeholders for feedback.

Results

Our map of the interventions used in Cameroon suggests that most childhood vaccination communication interventions focus on national campaigns against polio rather than routine immunisation. The map also indicates that most communication interventions target communities more broadly, rather than parents, and that very few interventions target health workers. The majority of the communication interventions aimed to inform or educate or remind or recall members of the community about vaccination. The COMMVAC taxonomy provided a useful framework for quickly and simply mapping existing vaccination communication strategies.

Conclusions

By identifying the interventions used in Cameroon and developing an intervention map, we allowed stakeholders to see where they were concentrating their communication efforts and where gaps exist, allowing them to reflect on whether changes are needed to the communication strategies they are using.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2557-9) contains supplementary material, which is available to authorized users.

Characteristics of Physicians Who Dismiss Families for Refusing Vaccines

BACKGROUND AND OBJECTIVES

Physicians dismissing families who refuse vaccines from their practices is controversial. We assessed the following among pediatricians (Peds) and family physicians (FPs): (1) reported prevalence of parental refusal of 1 or more vaccines in the infant series; (2) physician response to refusal; and (3) the association between often/always dismissing families and provider/practice characteristics and state exemption laws.

METHODS

Nationally representative survey conducted June to October 2012. A multivariable analysis assessed association of often/always dismissing families with physician/practice characteristics, state philosophical exemption policy, and degree of difficulty obtaining nonmedical exemptions.

RESULTS

The response rate was 66% (534/815). Overall, 83% of physicians reported that in a typical month, ≥1% of parents refused 1 or more infant vaccines, and 20% reported that >5% of parents refused. Fifty-one percent reported always/often requiring parents to sign a form if they refused (Peds 64%, FP 29%, P < .0001); 21% of Peds and 4% of FPs reported always/often dismissing families if they refused ≥1 vaccine. Peds only were further analyzed because few FPs dismissed families. Peds who dismissed families were more likely to be in private practice (adjusted odds ratio [aOR] 4.90, 95% confidence interval [CI] 1.40-17.19), from the South (aOR 4.07, 95% CI 1.08-15.31), and reside in a state without a philosophical exemption law (aOR 3.70, 95% CI 1.74-7.85).

CONCLUSIONS

Almost all physicians encounter parents who refuse infant vaccines. One-fifth of Peds report dismissing families who refuse, but there is substantial variation in this practice. Given the frequency of dismissal, the impact of this practice on vaccine refusers and on pediatric practices should be studied.

I Immunise: An evaluation of a values-based campaign to change attitudes and beliefs

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.

Parental views on childhood vaccination against viral gastroenteritis-a qualitative interview study

BACKGROUND

Gastroenteritis (GE) causes significant morbidity, especially in young children. A vaccine against rotavirus, a common cause of viral GE (vGE), was added to the childhood immunization schedule in the UK in July 2013 and further related vaccines are under development.

AIM

To explore parents' beliefs about vGE and their attitudes towards vaccinating.

DESIGN AND SETTING

Qualitative interview study with parents of children who had recently experienced an episode of GE.

METHOD

Twenty-eight semi-structured interviews were conducted over the phone with parents. Interviews were audio-recorded, transcribed and analysed using standard thematic approaches.

RESULTS

Parents varied in their perception of the threat posed by GE, and parents who did not perceive GE as serious were less enthusiastic about vaccines. Other parents were supportive of vaccines in general and considered benefits to their child, their family and the wider community. Many parents said that they lacked knowledge about efficacy and effectiveness of GE vaccines but their underlying belief about the seriousness of illness motivated their attitudes.

CONCLUSION

Acceptability of GE vaccines to parents could be improved by providing more information on both the burden of illness and the impact of rotavirus vaccine in other comparable countries.

Interventions aimed at communities to inform and/or educate about early childhood vaccination

BACKGROUND

A range of strategies are used to communicate with parents, caregivers and communities regarding child vaccination in order to inform decisions and improve vaccination uptake. These strategies include interventions in which information is aimed at larger groups in the community, for instance at public meetings, through radio or through leaflets. This is one of two reviews on communication interventions for childhood vaccination. The companion review focuses on face-to-face interventions for informing or educating parents.

OBJECTIVES

To assess the effects of interventions aimed at communities to inform and/or educate people about vaccination in children six years and younger.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE and five other databases up to July 2012. We searched for grey literature in the Grey Literature Report and OpenGrey. We also contacted authors of included studies and experts in the field. There were no language, date or settings restrictions.

SELECTION CRITERIA

Individual or cluster-randomised and quasi-randomised controlled trials, interrupted time series (ITS) and repeated measures studies, and controlled before-and-after (CBA) studies. We included interventions aimed at communities and intended to inform and/or educate about vaccination in children six years and younger, conducted in any setting. We defined interventions aimed at communities as those directed at a geographic area, and/or interventions directed to groups of people who share at least one common social or cultural characteristic. Primary outcomes were: knowledge among participants of vaccines or vaccine-preventable diseases and of vaccine service delivery; child immunisation status; and unintended adverse effects. Secondary outcomes were: participants' attitudes towards vaccination; involvement in decision-making regarding vaccination; confidence in the decision made; and resource use or cost of intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed the references to identify studies for inclusion. We extracted data and assessed risk of bias in all included studies.

MAIN RESULTS

We included two cluster-randomised trials that compared interventions aimed at communities to routine immunisation practices. In one study from India, families, teachers, children and village leaders were encouraged to attend information meetings where they received information about childhood vaccination and could ask questions. In the second study from Pakistan, people who were considered to be trusted in the community were invited to meetings to discuss vaccine coverage rates in their community and the costs and benefits of childhood vaccination. They were asked to develop local action plans and to share the information they had been given and continue the discussions in their communities.The trials show low certainty evidence that interventions aimed at communities to inform and educate about childhood vaccination may improve knowledge of vaccines or vaccine-preventable diseases among intervention participants (adjusted mean difference 0.121, 95% confidence interval (CI) 0.055 to 0.189). These interventions probably increase the number of children who are vaccinated. The study from India showed that the intervention probably increased the number of children who received vaccinations (risk ratio (RR) 1.67, 95% CI 1.21 to 2.31; moderate certainty evidence). The study from Pakistan showed that there is probably an increase in the uptake of both measles (RR 1.63, 95% CI 1.03 to 2.58) and DPT (diptheria, pertussis and tetanus) (RR 2.17, 95% CI 1.43 to 3.29) vaccines (both moderate certainty evidence), but there may be little or no difference in the number of children who received polio vaccine (RR 1.01, 95% CI 0.97 to 1.05; low certainty evidence). There is also low certainty evidence that these interventions may change attitudes in favour of vaccination among parents with young children (adjusted mean difference 0.054, 95% CI 0.013 to 0.105), but they may make little or no difference to the involvement of mothers in decision-making regarding childhood vaccination (adjusted mean difference 0.043, 95% CI -0.009 to 0.097).The studies did not assess knowledge among participants of vaccine service delivery; participant confidence in the vaccination decision; intervention costs; or any unintended harms as a consequence of the intervention. We did not identify any studies that compared interventions aimed at communities to inform and/or educate with interventions directed to individual parents or caregivers, or studies that compared two interventions aimed at communities to inform and/or educate about childhood vaccination.

AUTHORS' CONCLUSIONS

This review provides limited evidence that interventions aimed at communities to inform and educate about early childhood vaccination may improve attitudes towards vaccination and probably increase vaccination uptake under some circumstances. However, some of these interventions may be resource intensive when implemented on a large scale and further rigorous evaluations are needed. These interventions may achieve most benefit when targeted to areas or groups that have low childhood vaccination rates.'

The big picture in addressing vaccine hesitancy

Public acceptance of vaccination has never been a given. Today there is a set of societal circumstances that may contribute to a growing parental hesitancy about vaccination. These include: increasingly 'crowded' vaccination schedules; lower prevalence of vaccine-preventable diseases; greater access to, and more rapid dissemination of, vaccine-critical messages via digital networks; hyper-vigilance of parents in relation to children and risk; and an increasingly consumerist orientation to healthcare.

Understanding the main barriers to immunization in Colombia to better tailor communication strategies

Background

The Expanded Program on Immunization (EPI) in Colombia has made great advances since its inception in 1979; however, by 2010 vaccination coverage rates had been declining. In 2010, the EPI commissioned a nationwide study on practices on immunization, attitudes and knowledge, perceived service quality, and barriers to childhood immunization in order to tailor EPI communication strategies.

Methods

Colombia’s 32 geographical departments were divided into 10 regions. Interviewers from an independent polling company administered a survey to 4802 parents and guardians of children aged <5 years in these regions. To better assess barriers to vaccination, the study was designed to have 70% of participants who had children with incomplete vaccination schedules. Explanatory factorial, principal component, and cluster analyses were performed to place participants into a group (segment) representing the primary category of reasons respondents offered for not vaccinating their children. Types of barriers were then compared to other variables, such as service quality, communication preferences, and parental attitudes on vaccination.

Results

Although all respondents indicated that vaccines have health benefits, and 4738 (98.7%) possessed vaccination cards for their children, attitudes and knowledge were not always favorable to immunization. Six groups of immunization barriers were identified: 1) factors related to caregivers (24.4%), 2) vaccinators (19.7%), 3) health centers (18.0%), 4) the health system (13.4%), 5) concerns about adverse events (13.1%), and 6) cultural and religious beliefs (11.4%); groups 1, 5 and 6 together represented almost half (48.9%) of users, indicating problems related to the demand for vaccines as the primary barriers to immunization. Differences in demographics, communication preferences, and reported service quality were found among participants in the six groups and among participants in the 10 regions. Additionally, differences between how participants reported receiving information on vaccination and how they believed such information should be communicated were observed.

Conclusions

Better understanding immunization barriers and the users of the EPI can help tailor communication strategies to increase demand for immunization services. Results of the study have been used by Colombia’s EPI to inform the design of new communication strategies.

"Knowledge and attitudes of Spanish adolescent girls towards human papillomavirus infection: where to intervene to improve vaccination coverage"

Background

HPV vaccine coverage is far from ideal in Valencia, Spain, and this could be partially related to the low knowledge about the disease and the vaccine, therefore we assessed these, as well as the attitude towards vaccination in adolescent girls, and tried to identify independently associated factors that could potentially be modified by an intervention in order to increase vaccine coverage.

Methods

A cross sectional study was conducted in a random selection of schools of the Spanish region of Valencia. We asked mothers of 1278 girls, who should have been vaccinated in the 2011 campaign, for informed consent. Those that accepted their daughters’ participation, a questionnaire regarding the Knowledge of HPV infection and vaccine was passed to the girls in the school.

Results

833 mothers (65.1%) accepted participation. All their daughters’ responded the questionnaire. Of those, 89.9% had heard about HPV and they associated it to cervical cancer. Only 14% related it to other problems like genital warts. The knowledge score of the girls who had heard about HPV was 6.1/10. Knowledge was unrelated to the number of contacts with the health system (Pediatrician or nurse), and positively correlated with the discussions with classmates about the vaccine. Adolescents Spanish in origin or with an older sister vaccinated, had higher punctuation. 67% of the girls thought that the vaccine prevented cancer, and 22.6% felt that although prevented cancer the vaccine had important safety problems. 6.4% of the girls rejected the vaccine for safety problems or for not considering themselves at risk of infection. 71.5% of the girls had received at least one vaccine dose. Vaccinated girls scored higher knowledge (p = 0.05).

Conclusion

Knowledge about HPV infection and vaccine was fair in adolescents of Valencia, and is independent to the number of contacts with the health system, it is however correlated to the conversations about the vaccine with their peers and the vaccination status. An action to improve HPV knowledge through health providers might increase vaccine coverage in the adolescents.

Cochrane Consumers and Communication Review Group: leading the field on health communication evidence

This paper presents an overview of the history and achievements of the Cochrane Consumers and Communication Review Group, part of the international Cochrane Collaboration. It surveys the Group's establishment and structure, the scope of its Cochrane Reviews and the growth in its publication output over its 16-year history. The paper examines the Group's developmental work in interventions and outcomes related to patient communication and involvement, as well as methodological resources for review authors. It also outlines the Review Group's research partnerships with state, national and international agencies, particularly in the areas of chronic disease management, medicines use, public involvement, and vaccines communication. The Group's strong contribution to an evidence-base for health communication and participation are acknowledged.