Shared decision-making interventions: An overview and a meta-analysis of their impact on vaccine uptake

The impact of regional disparities on the availability of meningococcal vaccines in the US

BACKGROUND

In the United States (US), three types of vaccines are available to prevent invasive meningococcal disease (IMD), a severe and potentially fatal infection: quadrivalent conjugate vaccines against serogroups A, C, W, Y (MenACWY), and monovalent vaccines against serogroup B (MenB) as well as a newly licensed pentavalent vaccine (MenABCWY) protecting against serogroup A, B, C, W, and Y. The CDC's Advisory Committee on Immunization Practices (ACIP) routinely recommends MenACWY vaccine for all 11- to 12-year-olds with a booster dose at 16 years. MenB vaccination is recommended based on shared clinical decision-making (SCDM) for 16- to 23-year-olds. Recently, the pentavalent meningococcal vaccine (MenABCWY) was recommended by the ACIP. Meningococcal vaccine uptake is suboptimal across the country, particularly among individuals with lower socioeconomic status (SES), despite these recommendations. The objective of the spatial analyses was to assess the relationship between stocking of MenACWY and MenB vaccines, area-level SES, and state-level policies.

METHODS

The number of MenACWY and MenB doses stocked by vaccinators was obtained from IQVIA and the CDC's Vaccine for Children (VFC) program and compiled into a county-level dataset from 2016 to 2019. SES, as measured using the CDC's Social Vulnerability Index (SVI), state-level school recommendations, and universal purchasing programs were among the main county-level covariates included to control for factors likely influencing stocking. Data were stratified by public and private market. Bayesian spatial regression models were developed to quantify the variations in rates of stocking and the relative rates of stocking of both vaccines.

RESULTS

After accounting for county-level characteristics, lower SES counties tended to have fewer doses of MenB relative to MenACWY on both public and private markets. Lower SES counties tended to have more supply of public vs. private doses. Universal purchasing programs had a strong effect on the markets for both vaccines shifting nearly all doses to the public market. School vaccination strategy was key for improving stocking rates.

CONCLUSIONS

Overall, the results show that MenACWY has greater stock relative to MenB across the US. This difference is exacerbated in vulnerable areas without school entry requirements for vaccination and results in inequity of vaccine availability. Beyond state-level policy and SES differences, SCDM recommendations may be a contributing factor, although this was not directly assessed by our model.

Contributions and Impact of Health Communication Research to Vaccination Efforts and Acceptance

Vaccines (a medical product) and vaccination recommendations (expert advice on who should receive, when, and how often) have grown in importance and prominence in the past 15 years, including because of a recent COVID-19 pandemic. This essay highlights contributions from vaccine and vaccination-related health communication research since 2010. This research has had significant impacts - that is, visible and discernible positive effects - on the ways health communication is undertaken broadly (e.g. at the campaign level) and at the health care provider-patient level (e.g. conversations with parents and patients regarding vaccine benefits, risks, and safety). As this essay illustrates, health communication research has resulted in greater use of formative research to guide vaccination campaign and education efforts, better identification and understanding of the factors behind vaccination delay and declination, and greater recognition that communication efforts can fail to achieve desired outcomes or generate unintended consequences. Health communication research has also documented the powerful influence of healthcare provider communication on parent and patient understanding and compliance with immunization recommendations. Importantly, this research has also shown the characteristics of provider-patient communication matter much. Healthcare providers must have or establish a high degree of trust, be well-versed in vaccine efficacy and safety, and be adept at using their personal experiences, information tailoring/personalization, and evidence-based communication strategies to increase the likelihood of success.

Exploring Cultural and Religious Effects on HPV Vaccination Decision Making Using a Web-Based Decision Aid: A Quasi-experimental Study

BACKGROUND

Human papillomavirus (HPV) poses a significant public health concern, as it is linked to various serious health conditions such as cancer and genital warts. Despite the vaccine's safety, efficacy, and availability through national school programs, HPV vaccination rates remain low in Israel, particularly within the ultra-Orthodox community due to religious and cultural barriers. Decision aids have shown promise in facilitating shared decision making and promoting informed choices in health care. This study aimed to assess the impact of a novel Web-based decision aid on HPV vaccination intentions, knowledge, decision self-efficacy, and decisional conflict among Israeli parents and young adults, with a specific focus on exploring differences between religious groups.

METHODS

Two Web-based decision aids were developed for parents of children aged 10 to 17 y (n = 120) and young adults aged 18 to 26 y (n = 160). A quasi-experimental study was conducted among Hebrew-speaking parents and young adults eligible for HPV vaccination. Participants completed pre- and postintervention questionnaires assessing vaccination intentions, knowledge about HPV, decision self-efficacy, and decisional conflict.

RESULTS

The decision aid significantly improved intentions toward HPV vaccination among most religious groups, except the Jewish ultra-Orthodox community. Ultra-Orthodox participants exhibited reluctance to vaccinate themselves or their children (odds ratio [OR] = 0.23, P < 0.001 for parents' group; OR = 0.43, P < 0.001 for young adults' group). Parental preference for vaccinating girls over boys (OR = 2.66, P < 0.001) and increased inclination for vaccination among Muslim-Arabs were observed (OR = 3.12, P < 0.001). Knowledge levels improved among ultra-Orthodox participants but not decisional conflict and self-efficacy.

CONCLUSIONS

The Web-based decision aid positively influenced the quality of HPV vaccination decision making among various religious groups in Israel, except for the ultra-Orthodox community. Culturally tailored approaches that address specific community concerns are essential for informed decision making.

HIGHLIGHTS

Human papillomavirus (HPV) vaccination rates in Israel are substantially lower than those of other routine vaccinations, particularly among religious and ultra-Orthodox communities, largely due to sociocultural beliefs and misinformation.A newly developed Web-based decision aid was implemented in a study involving parents and young adults to evaluate its impact on vaccination intent, knowledge about HPV, decision self-efficacy, and decisional conflict.While the decision aid significantly enhanced vaccination intention, knowledge, and perceived behavioral control among various religious groups, it did not yield the same outcomes within the ultra-Orthodox Jewish community.This study highlights the vital role of cultural adaptation in HPV vaccine decision aids within Israel, revealing significant disparities in vaccination perceptions and decisions among diverse religious and cultural groups.

Ethics of Nudging in the COVID-19 Crisis and the Necessary Return to the Principles of Shared Decision Making: A Critical Review

Nudging, a controversial technique for modifying people's behavior in a predictable way, is claimed to preserve freedom of choice while simultaneously influencing it. Nudging had been largely confined to situations such as promoting healthy eating choices but has been employed in the coronavirus disease 2019 (COVID-19) crisis in a shift towards measures that involve significantly less choice, such as shoves and behavioral prods. Shared decision making (SDM), a method for direct involvement and autonomy, is an alternative approach to communicate risk. Predominantly peer-reviewed scientific publications from standard literature databases like PubMed, PsycInfo, and Psyndex were evaluated in a narrative review. The so-called fear nudges, as well as the dissemination of strongly emotionalizing or moralizing messages can lead to intense psycho-physical stress. The use of these nudges by specialized units during the COVID-19 pandemic generated a societal atmosphere of fear that precipitated a deterioration of the mental and physical health of the population. Major recommendations of the German COVID-19 Snapshot Monitoring (COSMO) study, which are based on elements of nudging and coercive measures, do not comply with ethical principles, basic psychological principles, or evidence-based data. SDM was misused in the COVID-19 crisis, which helped to achieve one-sided goals of governments. The emphasis on utilitarian thinking is criticized and the unethical behavior of decision makers is explained by both using the concept of moral disengagement and the maturity level of coping strategies. There should be a return to an open-ended, democratic, and pluralistic scientific debate without using nudges. It is therefore necessary to return to the origins of SDM.

National launch of human papillomavirus (HPV) immunization program in Poland, 2023

Poland launched a nationwide Human Papillomavirus (HPV) immunization program in June 2023, transitioning from a recommended to publicly funded approach. Targeting mainly 12 to 13-year-olds, the program offers universal and cost-free vaccinations with Cervarix and Gardasil 9. The initiative, aligned with the National Oncology Strategy, involves 4945 healthcare facilities, ensuring accessibility across regions. The streamlined process, empowering parents to choose, includes diverse healthcare professionals.

Implementing Effective Care in a University Population Based on National Vaccination Recommendations

Vaccines are among the most cost-effective and successful medical interventions, saving approximately 2.3 million lives annually. Unfortunately, vaccination coverage for adults remains low, leading to unnecessary and costly health consequences. An initial chart review revealed that 95% (N = 20) of students were not up to date with vaccines. In a patient survey, 100% of students (N = 21) did not recall receiving useful vaccine information, but 66.7% reported it would be helpful (≥4 of 5 on the Likert scale). Strategies supporting effective care, an Institute of Medicine quality domain, were used to address these gaps. The aim was to increase effective care in university adult students for vaccines by 30% over 90 days. The quality improvement method of Plan-Do-Study-Act cycles was used to evaluate iterative tests of change. Examining contextual elements, team and patient feedback, aggregate data, and run charts informed tests of change over 4 cycles. Core interventions included enhanced screening, vaccine shared decision-making, provider checklists, and a team engagement plan. Greater than 83% (N = 152) of students were not up to date with vaccines as per national guidelines. Over 8 weeks, the team effectively referred students for 265 of the 274 vaccines they were eligible for-an accuracy rate of 95.3%. The aim score, a mean composite score reflecting all 3 interventions, increased from 49% to 95%. Effective care for vaccine uptake increased by 83.8%-far exceeding the goal. Campus health centers and other primary care settings could benefit from adopting a similar strategy that provides clear benefits to patients and the broader community while decreasing health care costs.

A surgical decision aid for occipital neuralgia with literature review and single center case series

BACKGROUND

Occipital neuralgia (ON) is a debilitating headache disorder. Due to the rarity of this disorder and lack of high-level evidence, a clear framework for choosing the optimal surgical approach for medically refractory ON incorporating shared decision making with patients does not exist.

METHODS

A literature review of studies reporting pain outcomes of patients who underwent surgical treatment for ON was performed, as well as a retrospective chart review of patients who underwent surgery for ON within our institution.

RESULTS

Thirty-two articles met the inclusion criteria. A majority of the articles were retrospective case series (22/32). The mean number of patients across the studies was 34 (standard deviation (SD) 39). Among the 13 studies that reported change in pain score on 10-point scales, a study of 20 patients who had undergone C2 and/or C3 ganglionectomies reported the greatest reduction in pain intensity after surgery. The studies evaluating percutaneous ablative methods including radiofrequency ablation and cryoablation showed the smallest reduction in pain scores overall. At our institution from 2014 to 2023, 11 patients received surgical treatment for ON with a mean follow-up of 187 days (SD 426).

CONCLUSION

Based on these results, the first decision aid for selecting a surgical approach to medically refractory ON is presented. The algorithm prioritizes nerve sparing followed by non-nerve sparing techniques with the incorporation of patient preference. Shared decision making is critical in the treatment of ON given the lack of clear scientific evidence regarding the superiority of a particular surgical method.

Shared Decision-Making and Cardiovascular Health: A Scientific Statement From the American Heart Association

Shared decision-making is increasingly embraced in health care and recommended in cardiovascular guidelines. Patient involvement in health care decisions, patient-clinician communication, and models of patient-centered care are critical to improve health outcomes and to promote equity, but formal models and evaluation in cardiovascular care are nascent. Shared decision-making promotes equity by involving clinicians and patients, sharing the best available evidence, and recognizing the needs, values, and experiences of individuals and their families when faced with the task of making decisions. Broad endorsement of shared decision-making as a critical component of high-quality, value-based care has raised our awareness, although uptake in clinical practice remains suboptimal for a range of patient, clinician, and system issues. Strategies effective in promoting shared decision-making include educating clinicians on communication techniques, engaging multidisciplinary medical teams, incorporating trained decision coaches, and using tools (ie, patient decision aids) at appropriate literacy and numeracy levels to support patients in their cardiovascular decisions. This scientific statement shines a light on the limited but growing body of evidence of the impact of shared decision-making on cardiovascular outcomes and the potential of shared decision-making as a driver of health equity so that everyone has just opportunities. Multilevel solutions must align to address challenges in policies and reimbursement, system-level leadership and infrastructure, clinician training, access to decision aids, and patient engagement to fully support patients and clinicians to engage in the shared decision-making process and to drive equity and improvement in cardiovascular outcomes.

The Role of Adult Vaccines as Part of Antimicrobial Stewardship: A Scoping Review

BACKGROUND

Antimicrobial resistance (AMR) is a significant global health concern, causing an estimated 700,000 deaths annually. Although immunisation has been shown to significantly reduce AMR, the role of vaccines as part of antimicrobial stewardship (AMS) practices is often overlooked.

OBJECTIVE

To identify and examine the available literature on the role of vaccines as part of AMS practices.

METHOD

A scoping review was conducted in the following databases: MEDLINE, Embase, Scopus, CINAHL, CCRCT, IPA, and WoS, along with grey literature sources. The review was conducted using the JBI Methodology for Scoping Reviews and reported in line with the PRISMA-SCr checklist.

RESULTS

Among the 1711 records identified, 34 met the inclusion criteria; 8 discussed only the concept, while 26 discussed both the concept and the vaccine implementation method in AMS practices. There were eight recommended and/or utilised types of AMS activities identified involving vaccines, under four key themes of vaccine-related AMS strategies: Education, Screening, Vaccination, and Monitoring. Influenza and pneumococcal vaccines had the most evidence for inclusion.

CONCLUSION

Overall, the evidence supports the role of vaccines as part of AMS practices and the value of their inclusion in creating improved and comprehensive AMS strategies to further combat the development of AMR.

Strengthening scientific credibility in the face of misinformation and disinformation: Viable solutions

Despite numerous attempts to mitigate their spread, misinformation and disinformation are rampant on social media and other public networks, posing a substantial risk to public health and individual well-being. A concerted, multi-channel approach is required to effectively tackle this evolving problem. This paper outlines potential strategies and actionable plans to improve the response to misinformation and disinformation by stakeholders from various healthcare ecosystems.

Reducing COVID-19 Vaccine Decisional Conflict in Parents of 5-11-Year-Old Children in Australia: A Single Arm Pre-Post Study

COVID-19 vaccine uptake among 5-11-year-olds is significantly lower than that of the 12+ age group. Some parents may have decided against vaccinating their children for COVID-19; others may be undecided and may be seeking more information to support their decision. We aimed to assess the effect of a decision support tool on parents' level of decisional conflict, vaccine hesitancy, and intention to vaccinate. We conducted a single-arm, cross-sectional online pre-post intervention survey of parents from Victoria, Australia, who had not yet vaccinated their 5-11-year-old child for COVID-19. We measured change in decisional conflict, intention, and hesitancy towards COVID-19 vaccines for children before and after viewing a decision support tool. We used logistic regression to identify characteristics associated with reduced decisional conflict. Between May and September 2022, 108 parents took part in the study. The tool reduced decision conflict in 25% (27/107) of parents, with reduced decisional conflict more likely among parents initially undecided about vaccinating, compared to parents who did not intend to vaccinate their child (OR, 12.58 95% CI 3.21 to 9.30). For most parents, hesitancy (83%, 90/108) and intention (89%, 96/108) remained the same. The decision support tool was modestly effective at reducing decisional conflict, particularly among undecided parents.

The CONFIDENT study protocol: a randomized controlled trial comparing two methods to increase long-term care worker confidence in the COVID-19 vaccines

BACKGROUND

Clinical and real-world effectiveness data for the COVID-19 vaccines have shown that they are the best defense in preventing severe illness and death throughout the pandemic. However, in the US, some groups remain more hesitant than others about receiving COVID-19 vaccines. One important group is long-term care workers (LTCWs), especially because they risk infecting the vulnerable and clinically complex populations they serve. There is a lack of research about how best to increase vaccine confidence, especially in frontline LTCWs and healthcare staff. Our aims are to: (1) compare the impact of two interventions delivered online to enhanced usual practice on LTCW COVID-19 vaccine confidence and other pre-specified secondary outcomes, (2) determine if LTCWs' characteristics and other factors mediate and moderate the interventions' effect on study outcomes, and (3) explore the implementation characteristics, contexts, and processes needed to sustain a wider use of the interventions.

METHODS

We will conduct a three-arm randomized controlled effectiveness-implementation hybrid (type 2) trial, with randomization at the participant level. Arm 1 is a dialogue-based webinar intervention facilitated by a LTCW and a medical expert and guided by an evidence-based COVID-19 vaccine decision tool. Arm 2 is a curated social media web application intervention featuring interactive, dynamic content about COVID-19 and relevant vaccines. Arm 3 is enhanced usual practice, which directs participants to online public health information about COVID-19 vaccines. Participants will be recruited via online posts and advertisements, email invitations, and in-person visits to care settings. Trial data will be collected at four time points using online surveys. The primary outcome is COVID-19 vaccine confidence. Secondary outcomes include vaccine uptake, vaccine and booster intent for those unvaccinated, likelihood of recommending vaccination (both initial series and booster), feeling informed about the vaccines, identification of vaccine information and misinformation, and trust in COVID-19 vaccine information provided by different people and organizations. Exploration of intervention implementation will involve interviews with study participants and other stakeholders, an in-depth process evaluation, and testing during a subsequent sustainability phase.

DISCUSSION

Study findings will contribute new knowledge about how to increase COVID-19 vaccine confidence and effective informational modalities for LTCWs.

TRIAL REGISTRATION

NCT05168800 at ClinicalTrials.gov, registered December 23, 2021.

Implementation of Shared Decision-Making Within Internet Hospitals in China Based on Patients' Needs: Feasibility Study and Content Analysis

BACKGROUND

Internet hospitals are developing rapidly in China, and their convenient and efficient medical services are being increasingly recognized by patients. Many hospitals have set up their own internet hospitals to provide web-based medical services. Tianjin Medical University General Hospital has established a multidisciplinary and comprehensive internet hospital to provide diversified medical services according to the needs of patients. A way to further improve web-based medical services is by examining how shared decision-making (SDM) can be carried out in internet hospital diagnosis and treatment services, thereby improving patients' medical experience.

OBJECTIVE

The aim of this study was to analyze the feasibility of implementing doctor-patient SDM in internet hospital diagnosis and treatment services based on patients' needs in China.

METHODS

In this study, the medical data of 10 representative departments in the internet hospital of Tianjin Medical University General Hospital from January 1 to January 31, 2022, were extracted as a whole; 25,266 cases were selected. After excluding 2056 cases with incomplete information, 23,210 cases were finally included in this study. A chi-square test was performed to analyze the characteristics and medical service needs of internet hospital patients in order to identify the strengths of SDM in internet hospitals.

RESULTS

The internet hospital patients from 10 clinical departments were significantly different in terms of gender (χ²₉=3425.6; P<.001), age (χ²₃₆=27,375.8; P<.001), mode of payment (χ²₉=3501.1; P<.001), geographic distribution (χ²₉=347.2; P<.001), and duration of illness (χ²₃₆=2863.3; P<.001). Patient medical needs included drug prescriptions, examination prescriptions, medical record explanations, drug use instructions, prehospitalization preparations, further consultations with doctors (unspecified purpose), treatment plan consultations, initial diagnoses based on symptoms, and follow-up consultations after discharge. The medical needs of the patients in different clinical departments were significantly different (χ²₇₂=8465.5; P<.001).

CONCLUSIONS

Our study provides a practical and theoretical basis for the feasibility of doctor-patient SDM in internet hospitals and offers some implementation strategies. We focus on the application of SDM in web-based diagnosis and treatment in internet hospitals rather than on a disease or a disease management software. The medical service needs of different patient groups can be effectively obtained from an internet hospital, which provides the practical conditions for the promotion of doctor-patient SDM. Our findings show that the internet hospital platform expands the scope of SDM and is a new way for the large-scale application of doctor-patient SDM.

Human Papillomavirus vaccination clinical decision support for young adults in an upper midwestern healthcare system: a clinic cluster-randomized control trial

INTRODUCTION

Human papillomavirus (HPV) vaccination rates are low in young adults. Clinical decision support (CDS) in primary care may increase HPV vaccination. We tested the treatment effect of algorithm-driven, web-based, and electronic health record-linked CDS with or without shared decision-making tools (SDMT) on HPV vaccination rates compared to usual care (UC).

METHODS

In a clinic cluster-randomized control trial conducted in a healthcare system serving a largely rural population, we randomized 34 primary care clinic clusters (with three clinics sharing clinicians randomized together) to: CDS; CDS+SDMT; UC. The sample included young adults aged 18-26 due for HPV vaccination with a study index visit from 08/01/2018-03/15/2019 in a study clinic. Generalized linear mixed models tested differences in HPV vaccination status 12 months after index visits by study arm.

RESULTS

Among 10,253 patients, 6,876 (65.2%) were due for HPV vaccination, and 5,054 met study eligibility criteria. In adjusted analyses, the HPV vaccination series was completed by 12 months in 2.3% (95% CI: 1.6%-3.2%) of CDS, 1.6% (95% CI: 1.1%-2.3%) of CDS+SDMT, and 2.2% (95% CI: 1.6%-3.0%) of UC patients, and at least one HPV vaccine was received by 12 months in 13.1% (95% CI: 10.6%-16.1%) of CDS, 9.2% (95% CI: 7.3%-11.6%) of CDS+SDMT, and 11.2% (95% CI: 9.1%-13.7%) of UC patients. Differences were not significant between arms. Females, those with prior HPV vaccinations, and those seen at urban clinics had significantly higher odds of HPV vaccination in adjusted models.

DISCUSSION

CDS may require optimization for young adults to significantly impact HPV vaccination.

TRIAL REGISTRATION

clinicaltrials.gov NCT02986230, 12/6/2016.