Vaccine Hesitancy in Rural Pediatric Primary Care

Urban and rural healthcare providers' perspectives on HPV vaccination in Minnesota

Human papillomavirus (HPV) vaccination can dramatically reduce the incidence of HPV-associated cancers. However, HPV vaccination coverage in rural areas is lower than in urban areas, and overall HPV vaccination coverage in the United States remains lower than other adolescent vaccines. We conducted 20 qualitative interviews with adolescent healthcare providers and clinic staff in urban and rural Minnesota and assessed their perspectives on HPV vaccination. Guiding interview topics included: strategies to persuade families to vaccinate their children, the impact of the patient-provider relationship and the clinical environment on vaccination uptake, and provider perceptions of parents' vaccine attitudes. In thematic analysis, all participants reported using common vaccination strategies, such as framing the HPV vaccine in terms of cancer prevention. The analysis also revealed three themes described as occurring uniquely or more intensely in rural communities than urban communities: the rural value of choice or independence, the spread of misinformation, and close-knit, multifaceted patient-provider relationships in clinical practice. Interventions aimed at increasing HPV vaccination should consider the distinctive circumstances of rural healthcare providers and patients.

Childhood Vaccination Practices and Parental Hesitancy Barriers in Rural and Urban Primary Care Settings

The purpose of our study was to identify primary care providers' (PCPs') practices in promoting childhood vaccination and their perceptions regarding barriers to vaccination in a primarily rural state. In January-May 2022, we conducted a mail and online survey of PCPs across Montana (n = 829). The survey included modules on routine immunizations in children 0-2 years old and COVID-19 vaccination in children 5-17 years old. The survey response rate was 36% (298/829). We categorized PCPs as working in rural (n = 218) or urban areas (n = 80), based on Rural-Urban Commuting Area codes. We then compared responses between rural and urban PCPs using chi-square tests. Urban PCPs (90-94%, depending on vaccine) stocked routinely recommended vaccines more frequently than rural PCPs (71-84%), but stocked the COVID-19 vaccine less often than rural PCPs (44% vs. 71%, respectively, p < 0.001). A higher percentage of rural providers reported parental beliefs that vaccine-preventable diseases are not severe enough to warrant vaccination (48% vs. 31%, p = 0.01) and concerns that vaccination will weaken their child's immune system (29% vs. 6%, p < 0.001). More rural (74%) compared to urban (59%) PCPs identified a social media campaign from local health departments promoting early childhood vaccinations as an effective strategy to increase childhood vaccination rates (p = 0.01). We identified key differences in some childhood vaccination practices and barriers between rural and urban PCPs. Interventions to increase rural vaccination rates could include increasing the number of providers stocking all recommended vaccines, identifying strategies to address parents' concerns regarding vaccine necessity, and collaborations with public health departments.

Addressing Vaccine Hesitancy Among Students and Families: Interventions for School Nurses

Vaccine hesitance is a public health issue that school nurses often address in practice. It has become even more prevalent during the coronavirus disease 2019 (COVID-19) pandemic. Vaccine compliance among schoolchildren is essential to the health of an entire community, given that many pediatric illnesses are vaccine-preventable. School nurses are involved in the promotion of vaccines in a school district, as they provide health education to students and families and are responsible for vaccine surveillance. Promoting vaccine compliance as a matter of public health can be challenging for school nurses, especially if a community holds strong beliefs regarding the necessity of pediatric vaccines. This article reviews the history of vaccine mandates, addresses challenges associated with vaccine compliance, and provides interventions school nurses can use when providing care to students and families regarding vaccine hesitancy. In following the nursing process, a school nurse is able to identify students missing vaccine(s) and evaluate for hesitancy, before implementing interventions that provide education to students and families. Several cost-efficient and accessible interventions can facilitate effective education and promote vaccine compliance. School nurses can forge trusting relationships and engage in compassionate dialogue to support vaccine compliance in the school.

Clinician Communication to Address Vaccine Hesitancy

There are several factors that influence childhood vaccine uptake. Pediatric clinicians play a particularly influential role in parent vaccine decision-making. It is critical therefore that pediatric clinicians have a "communication toolbox"--a set of effective, evidence-based communication strategies to facilitate uptake of childhood vaccines--that they can use in conversations with parents about vaccines. In this article, recent advances in our understanding of what constitutes effective clinician vaccine communication with parents are discussed.

A systematic literature review to clarify the concept of vaccine hesitancy

Vaccine hesitancy (VH) is considered a top-10 global health threat. The concept of VH has been described and applied inconsistently. This systematic review aims to clarify VH by analysing how it is operationalized. We searched PubMed, Embase and PsycINFO databases on 14 January 2022. We selected 422 studies containing operationalizations of VH for inclusion. One limitation is that studies of lower quality were not excluded. Our qualitative analysis reveals that VH is conceptualized as involving (1) cognitions or affect, (2) behaviour and (3) decision making. A wide variety of methods have been used to measure VH. Our findings indicate the varied and confusing use of the term VH, leading to an impracticable concept. We propose that VH should be defined as a state of indecisiveness regarding a vaccination decision.

Best shot: A motivational interviewing approach to address vaccine hesitancy in pediatric outpatient settings

BACKGROUND

Vaccine hesitancy in parents and childhood vaccine refusal is increasing. A standard of care to address this problem has not been identified.

PURPOSE

To identify if the use of motivational interviewing by pediatric providers during routine well child visits, when compared to standard of care, would increase vaccine rates in children 0-12 months of age. Factors associated with vaccine hesitancy were also investigated.

METHODS

A quasi-experimental study was completed on a convenience sample of pediatric providers (N = 6) and caregivers of children 0-12 months of age (N = 66). Four providers were trained to use motivational interviewing. During the well child visit the Parent Attitudes About Childhood Vaccines survey was completed, and the motivational interviewing intervention was implemented. Clinic's data were compared with other clinic data of non-trained providers.

FINDINGS

Vaccine refusal/delays rate was 11.4% among caregivers. Vaccine refusal rate decreased after the intervention (9.00% pre-intervention and 6.40% post-intervention). An ordinal regression identified caregivers with higher vaccine hesitancy scores and more children were more likely to delay or refuse vaccines, while caregivers ≥30 years or with high income were less likely to delay/refuse vaccines. A difference in difference analysis identified that an additional 2.6% of children received vaccines when seen by trained providers compared to non-trained (β = -0.330, OR = 0.719, p = 0.470).

DISCUSSION

Findings indicate a condensed motivational interviewing education session may be clinically significant in decreasing vaccine hesitancy among this population.

APPLICATIONS TO PRACTICE

A more robust study to confirm these findings is recommended prior to practice implementation.

Barriers to and facilitators of early childhood immunization in rural areas of the United States: a systematic review of the literature

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Early childhood vaccination coverage is low in rural areas of the United States.

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Reminder-recall & positive family-provider relationships facilitate vaccine uptake.

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Parental hesitancy is a barrier to early childhood vaccination in the rural U.S.

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Vaccine referrals & distance to providers are also rural-specific barriers.

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To increase vaccine coverage, interventions across rural populations are needed.

Early childhood vaccination rates are lower in rural areas of the U.S. compared with suburban and urban areas. Our aim was to identify barriers to and facilitators of early childhood immunization in rural U.S. communities. We completed a systematic review of original research conducted in the U.S. between January 1, 2000-July 25, 2021. We searched PubMed, Cumulative Index for Nursing and Allied Health Literature, and Web of Science. We included studies that examined barriers to and facilitators of routine immunizations in children <36 months old in rural areas. Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, we reported studies’ methodologies and targeted populations, definitions of rurality, and common themes across studies that reflected barriers to or facilitators of vaccination. Ultimately, 17 papers met inclusion criteria for review. The majority of studies (10/17) were conducted within one U.S. state, and the same number (10/17) were conducted prior to 2005. Facilitators of vaccine uptake in rural communities identified across studies included reminder/recall systems and parents’ relationships with providers. Parental hesitancy, negative clinic experiences, referrals outside of primary care settings, and distance to providers were identified as barriers to vaccination in rural settings. This review revealed a limited scope of evidence on barriers to and facilitators of early childhood immunization in rural communities. More investigations of the causes of low vaccine coverage and the effectiveness of interventions for increasing vaccine uptake are urgently needed in rural pediatric populations to address persistent rural–urban immunization disparities.

Promoting Strategies to Increase HPV Vaccination in the Pediatric Primary Care Setting

INTRODUCTION

Evaluation of a quality improvement project designed to improve HPV vaccine uptake in a pediatric primary care setting for young adolescents.

METHOD

Three strategies were implemented in one private pediatric practice to promote HPV vaccine uptake for 11- and 12-year-old adolescents. 1) a standardized vaccine policy change was made to include HPV vaccine with other adolescent vaccines, 2) a pre-visit email was sent to parents of teens to provide factual vaccine information in preparation for the visit, and 3) a provider communication initiative was implemented to ensure all providers communicated consistent messages and delivered an effective cancer prevention recommendation for HPV vaccination. A pre/post design was used to compare vaccine rates. Data was obtained via the electronic health records.

RESULTS

The post-intervention group demonstrated HPV vaccine rates increased substantially from 17.8% to 63.6%.

DISCUSSION

Strategically implementing standardized clinical vaccine policies and presumprive provider communication practices has implications for significantly increasing HPV vaccine uptake among teens and may be key to preventing cancer among future generations.

Timeliness of Early Childhood Vaccinations and Undervaccination Patterns in Montana

INTRODUCTION

Early childhood vaccination rates are lower in rural areas than those in urban areas of the U.S. This study's objective is to quantify vaccine timeliness and the prevalence of undervaccination patterns in Montana and to measure the associations between timeliness and series completion by age 24 months.

METHODS

Using records from January 2015 to November 2019 in Montana's centralized immunization information system, days undervaccinated were calculated for the combined 7-vaccine series. Undervaccination patterns indicative of certain barriers to vaccination, including parental vaccine hesitancy, were identified. Using multivariable log-linked binomial regression, the association between timing of vaccine delay and not completing the combined 7-vaccine series by age 24 months was assessed. Analyses were conducted in March 2020-August 2020.

RESULTS

Among 31,422 children, 38.0% received all vaccine doses on time; 24.3% received all doses, but some were received late; and 37.7% had not completed the combined 7-vaccine series. Approximately 18.7% had an undervaccination pattern suggestive of parental vaccine hesitancy, and 19.7% started all series but were missing doses needed for multidose series completion. Although falling behind on vaccinations at any age was associated with failing to complete the combined 7-vaccine series, being late at age 12-15 months had the strongest association (adjusted prevalence ratio=3.73, 95% CI=3.56, 3.91) compared with being on time at age 12-15 months.

CONCLUSIONS

Fewer than 2 in 5 Montana children were fully vaccinated on time for the combined 7-vaccine series. To increase vaccination rates, initiatives to increase vaccine confidence and remind parents to complete vaccine series are needed.