Risk Communication, Values Clarification, and Vaccination Decisions

Perceptions of dengue risk and acceptability of a dengue vaccine in residents of Puerto Rico

Dengvaxia is the first dengue vaccine recommended in the United States (U.S.). It is recommended for children aged 9-16 y with laboratory-confirmed previous dengue infection and living in areas where dengue is endemic. We conducted focus groups with parents and in-depth interviews with key informants (i.e. practicing pediatricians, physicians from immunization clinics, university researchers, and school officials) in Puerto Rico (P.R.) to examine acceptability, barriers, and motivators to vaccinate with Dengvaxia. We also carried out informal meetings and semi-structured interviews to evaluate key messages and educational materials with pediatricians and parents. Barriers to vaccination included lack of information, distrust toward new vaccines, vaccine side effects and risks, and high cost of/lack of insurance coverage for laboratory tests and vaccines. Motivators included clear information about the vaccine, a desire to prevent future dengue infections, the experience of a previous dengue infection or awareness of dengue fatality, vaccine and laboratory tests covered by health insurance, availability of rapid test results and vaccine appointments. School officials and parents agreed parents would pay a deductible of $5-20 for Dengvaxia. For vaccine information dissemination, parents preferred an educational campaign through traditional media and social media, and one-on-one counseling of parents by healthcare providers. Education about this vaccine to healthcare providers will help them answer parents' questions. Dengvaxia acceptability in P.R. will increase by addressing motivators and barriers to vaccination and by disseminating vaccine information in plain language through spokespersons from health institutions in P.R.

Development of Promising Interventions to Improve Human Papillomavirus Vaccination in a School-Based Program in Quebec, Canada: Results From a Formative Evaluation Using a Mixed Methods Design

BACKGROUND

Despite the availability of school-based human papillomavirus (HPV) vaccination programs, disparities in vaccine coverage persist. Barriers to HPV vaccine acceptance and uptake include parental attitudes, knowledge, beliefs, and system-level barriers. A total of 3 interventions were developed to address these barriers: an in-person presentation by school nurses, an email reminder with a web-based information and decision aid tool, and a telephone reminder using motivational interviewing (MI) techniques.

OBJECTIVE

Here we report on the development and formative evaluation of interventions to improve HPV vaccine acceptance and uptake among grade 4 students' parents in Quebec, Canada.

METHODS

In the summer of 2019, we conducted a formative evaluation of the interventions to assess the interventions' relevance, content, and format and to identify any unmet needs. We conducted 3 focus group discussions with parents of grade 3 students and nurses. Interviews were recorded, transcribed, and analyzed for thematic content using NVivo software (Lumivero). Nurses received training on MI techniques and we evaluated the effect on nurses' knowledge and skills using a pre-post questionnaire. Descriptive quantitative analyses were carried out on data from questionnaires relating to the training. Comparisons were made using the proportions of the results. Finally, we developed a patient decision aid using an iterative, user-centered design process. The iterative refinement process involved feedback from parents, nurses, and experts to ensure the tool's relevance and effectiveness. The evaluation protocol and data collection tools were approved by the CHU (Centre Hospitalier Universitaire) de Québec Research Ethics Committee (MP-20-2019-4655, May 16, 2019).

RESULTS

The data collection was conducted from April 2019 to March 2021. Following feedback (n=28) from the 3 focus group discussions in June 2019, several changes were made to the in-person presentation intervention. Experts (n=27) and school nurses (n=29) recruited for the project appreciated the visual and simplified information on vaccination in it. The results of the MI training for school nurses conducted in August 2019 demonstrated an increase in the skills and knowledge of nurses (n=29). School nurses who took the web-based course (n=24) filled out a pretest and posttest questionnaire to evaluate their learning. The rating increased by 19% between the pretest and posttest questionnaires. Several changes were made between the first draft of the web-based decision-aid tool and the final version during the summer of 2019 after an expert consultation of experts (n=3), focus group participants (n=28), and parents in the iterative process (n=5). More information about HPV and vaccines was added, and users could click if more detail is desired.

CONCLUSIONS

We developed and pilot-tested 3 interventions using an iterative process. The interventions were perceived as potentially effective to increase parents' knowledge and positive attitudes toward HPV vaccination, and ultimately, vaccine acceptance. Future research will assess the effectiveness of these interventions on a larger scale.

Development of the AMPDECIDE Decision Aid to Facilitate Shared Decision Making in Patients Facing Amputation Secondary to Chronic Limb Threatening Ischemia

INTRODUCTION

We developed a patient decision aid to enhance patient participation in amputation level decision making when there is a choice between a transmetatarsal or transtibial amputation.

METHODS

In accordance with International Patient Decision Aid Standards, we developed an amputation level patient decision aid for patients who are being considered for either a transmetatarsal or transtibial amputation, incorporating qualitative literature data, quantitative literature data, qualitative provider and patient interviews, expert panel input and iterative patient feedback.

RESULTS

The rapid qualitative literature review and qualitative interviews identified five domains outcome priority domains important to patients facing amputation secondary to chronic limb threatening ischemia: 1) the ability to walk, 2) healing and risk for reamputation, 3) rehabilitation program intensity, 4) ease of prosthetic use, and 5) limb length after amputation. The rapid quantitative review identified only two domains with adequate evidence comparing differences in outcomes between the two amputation levels: mobility and reamputation. Patient, surgeon, rehabilitation and decision aid expert feedback allowed us to integrate critical facets of the decision including addressing the emotional context of loss of limb, fear and anxiety as an obstacle to decision making, shaping the decision in the context of remaining life years, and how to facilitate patient knowledge of value tradeoffs.

CONCLUSIONS

Amputation level choice is associated with significant outcome trade-offs. The AMPDECIDE patient decision aid can facilitate acknowledgment of patient fears, enhance knowledge of amputation level outcomes, assist patients in determining their personal outcome priorities, and facilitate shared amputation level decision making.

Interventions for COVID-19 Vaccine Hesitancy: A Systematic Review and Narrative Synthesis

Vaccines effectively protect against COVID-19, but vaccine hesitancy and refusal hinder vaccination rates. This systematic review aimed to (1) review and describe current interventions for addressing COVID-19 vaccine hesitancy/refusal and (2) assess whether these interventions are effective for increasing vaccine uptake. The protocol was registered prospectively on PROSPERO and comprehensive search included Medline, Embase, CINAHL, PsycInfo, and Web of Science databases. Only studies that evaluated the effectiveness of non-financial interventions to address COVID-19 vaccine hesitancy were included, while those focusing intentions or financial incentive were excluded. Risk of bias for all included studies was evaluated using Cochrane risk of bias tools. In total, six articles were included in the review (total participants n = 200,720). A narrative synthesis was performed due to the absence of common quantitative metrics. Except for one randomized controlled trial, all studies reported that interventions were effective, increasing COVID-19 vaccination rates. However, non-randomized studies were subject to confounding biases. Evidence on the effectiveness of COVID-19 vaccine hesitancy interventions remains limited and further evidence is needed for the development of clear guidance on effective interventions to increase vaccine uptake.

Development and Appraisal of a Web-Based Decision Aid for HPV Vaccination for Young Adults and Parents of Children in Israel-A Quasi-Experimental Study

BACKGROUND

This study aimed to develop and evaluate the effectiveness of two web-based decision aids designed to help parents of children aged 10-17 years and young adults aged 18-26 years make informed decisions about the HPV vaccine.

METHODS

The decision aids were developed according to the International Patient Decision Aid Standards (IPDAS) criteria and included information about the vaccine, probabilities of benefits and side effects, personal narratives, and values clarification. The study utilized a quasi-experimental design and included 120 Hebrew-speaking parents and 160 young adults. Participants completed baseline surveys and, two weeks after using the decision aid, completed a follow-up survey.

RESULTS

Both parents and young adults experienced a reduction in decisional conflict, an increase in self-efficacy, and greater confidence in the safety and effectiveness of the vaccine. The proportion of participating parents deciding to vaccinate their children against HPV increased from 46% to 75%, and the proportion of participating young adults leaning towards receiving the HPV vaccine increased from 64% to 92%.

CONCLUSIONS

The study highlights the importance of using decision aids to support informed decision making about vaccination and suggests that web-based decision aids may be a useful tool for supporting Israeli parents and young adults to make HPV vaccination decisions.

A Voice-Annotated Digital Decision Aid to Promote Child Influenza Vaccination: A Feasibility Study

(1) Background: Child influenza vaccine uptake is suboptimal due partly to vaccine hesitancy. A voice-annotated digital decision aid, Flu Learning Object (FLO), was developed to facilitate parental decision-making. This study assessed parental views on FLO’s usability and utility and determined its preliminary effectiveness in increasing vaccine intention and uptake; (2) Methods: A single-center mixed method study was conducted in a public primary care clinic in Singapore. Parents of children aged 6 months to 5 years who were unvaccinated in the preceding year were recruited. In-depth interviews explored their views of using FLO. Pre- and post-FLO questionnaires assessed their vaccine intention and perceived usability using the System Usability Scale (SUS); (3) Results: 18 parents were recruited. They became more aware of benefits and potential complications, distinguished influenza from the common cold, and recognized recommendations by National Childhood Immunisation Schedule. FLO addressed parents’ concerns and supported their decision-making process. FLO has good usability with a mean SUS score of 79.3, ranked at approximately the 85th percentile. The usage of FLO significantly increased vaccine intention from 55.6% to 94.4% (p = 0.016) with an actual vaccine uptake rate of 50%; (4) Conclusions: Parents generally accepted FLO, which positively influenced their intention to vaccinate their child against influenza.

The intersection of gender and race in older adults' decision to receive COVID-19 vaccines

COVID-19 vaccines are essential public health tools for protecting older adults, who are at high risk of severe outcomes associated with COVID-19. Little is known, however, about how older adults approach the decision to receive a COVID-19 vaccine. We hypothesized that intersections between gender and race may provide unique insight into the decision-making process and the factors that lead to vaccine uptake among hesitant individuals. We performed in-depth interviews with 24 older adults who had been vaccinated against COVID-19 and used the framework approach with an intersectional lens to analyze data. Two typologies emerged: eager compliers did not question the need to vaccinate, whereas hesitant compliers were skeptical of the vaccine and underwent a thorough decision-making process prior to vaccination. For eager compliers, the vaccine offered protection from a disease that posed a serious threat, and few risks were perceived. In contrast, hesitant compliers perceived risks associated with the vaccine product or mistrusted the infrastructure that led to rapid vaccine development. Hesitancy was greater among Black participants, and only Black participants reported mistrust in vaccine infrastructure. At the intersection of gender and race, a 'White male effect' was observed, whereby White men perceived the fewest risks associated with the vaccine, and Black women were the most fearful of serious side effects. Nearly all hesitant compliers ultimately got vaccinated due to the threat of COVID-19. Convenient access through vaccine clinics in senior's buildings was pivotal for hesitant compliers and external and internal influences had differential impacts by race and gender. Emphasizing the risk of COVID-19, convenient and accessible opportunities for vaccination, and messages that are targeted to specific groups are likely to increase vaccine uptake among older adults.

Using Behavioral Science to Address COVID-19 Vaccine Hesitancy Among Cancer Survivors: Communication Strategies and Research Opportunities

Due to cancer survivors’ increased vulnerability to complications from COVID-19, addressing vaccine hesitancy and improving vaccine uptake among this population is a public health priority. However, several factors may complicate efforts to increase vaccine confidence in this population, including the underrepresentation of cancer patients in COVID-19 vaccine trials and distinct recommendations for vaccine administration and timing for certain subgroups of survivors. Evidence suggests vaccine communication efforts targeting survivors could benefit from strategies that consider factors such as social norms, risk perceptions, and trust. However, additional behavioral research is needed to help the clinical and public health community better understand, and more effectively respond to, drivers of vaccine hesitancy among survivors and ensure optimal protection against COVID-19 for this at-risk population. Knowledge generated by this research could also have an impact beyond the current COVID-19 pandemic by informing future vaccination efforts and communication with cancer survivors more broadly.

Clarifying Values: An Updated and Expanded Systematic Review and Meta-Analysis

Background

Patient decision aids should help people make evidence-informed decisions aligned with their values. There is limited guidance about how to achieve such alignment.

Purpose

To describe the range of values clarification methods available to patient decision aid developers, synthesize evidence regarding their relative merits, and foster collection of evidence by offering researchers a proposed set of outcomes to report when evaluating the effects of values clarification methods.

Data Sources

MEDLINE, EMBASE, PubMed, Web of Science, the Cochrane Library, and CINAHL.

Study Selection

We included articles that described randomized trials of 1 or more explicit values clarification methods. From 30,648 records screened, we identified 33 articles describing trials of 43 values clarification methods.

Data Extraction

Two independent reviewers extracted details about each values clarification method and its evaluation.

Data Synthesis

Compared to control conditions or to implicit values clarification methods, explicit values clarification methods decreased the frequency of values-incongruent choices (risk difference, –0.04; 95% confidence interval [CI], –0.06 to –0.02; P < 0.001) and decisional conflict (standardized mean difference, –0.20; 95% CI, –0.29 to –0.11; P < 0.001). Multicriteria decision analysis led to more values-congruent decisions than other values clarification methods (χ² = 9.25, P = 0.01). There were no differences between different values clarification methods regarding decisional conflict (χ² = 6.08, P = 0.05).

Limitations

Some meta-analyses had high heterogeneity. We grouped values clarification methods into broad categories.

Conclusions

Current evidence suggests patient decision aids should include an explicit values clarification method. Developers may wish to specifically consider multicriteria decision analysis. Future evaluations of values clarification methods should report their effects on decisional conflict, decisions made, values congruence, and decisional regret.

A systematic review and meta-analysis of effectiveness of decision aids for vaccination decision-making

BACKGROUND

This systematic review and meta-analysis aimed to assess the effectiveness of vaccination decision aids compared with usual care on vaccine uptake, vaccine attitudes, decisional conflict, intent to vaccinate and timeliness.

METHODS

Searches were conducted in OVID Medline, OVID Embase, CINAHL, PsycINFO, the Cochrane Library and SCOPUS. Randomised controlled trials were included if they evaluated the impact of decision aids as defined by the International Patient Decision Aids Standards Collaboration. Where possible, meta-analysis was undertaken. Where meta-analysis was not possible, we conducted a narrative synthesis. Risk of bias in included trials was assessed using the Cochrane Collaboration's risk of bias tool. Data were analysed using STATA.

RESULTS

Five RCTs were identified that evaluated the effectiveness of decision aids in the context of vaccination decision making. Meta-analysis of four studies showed that decision aids may have slightly increased vaccination uptake, but this was reduced to no effect once studies with higher risk of bias were excluded. Meta-analysis of three studies showed that decision aids moderately increased intention to vaccinate. Narrative synthesis of two studies suggested that decision aids reduced decisional conflict. One study reported that decision aids decreased perceived risk of vaccination. Content, format and delivery method of the decision aids varied across the studies. It was not clear from the information reported whether these variations affected the effectiveness of the decision aids.

CONCLUSION

Decision aids can assist in vaccine decision making. Future studies of decision aids could provide greater detail of the decision aids themselves, which would enable comparison of the effectiveness of different elements and formats. Standardising decision aids would also allow for easier comparison between decision aids.

Decision-making on maternal pertussis vaccination among women in a vaccine-hesitant religious group: Stages and needs

INTRODUCTION

As of December 2019, pregnant women in the Netherlands are offered pertussis vaccination to protect their newborn infant against pertussis infection. However, the manner in which pregnant women decide about this maternal pertussis vaccination is largely unknown. The aim of this study is to gain insight into the decision-making process regarding maternal pertussis vaccination, and to explore the related needs among the vaccine-hesitant subgroup of orthodox Protestant women.

METHODS

Charmaz's grounded theory approach was used to develop a decision-making framework. To construct this framework we used an explorative multimethod approach in which in-depth interviews and online focus groups were supplemented by a literature search and research group meetings. This study was carried out in a hypothetical situation since the maternal pertussis vaccination had yet to be implemented in the Dutch immunisation programme at the time of the study.

RESULTS

Twenty-five orthodox Protestant women participated in an interview, an online focus group, or in both. The findings of this study resulted in a decision-making framework that included three stages of decision-making; an Orientation stage, a value-based Deliberation stage, and Final decision stage. The Orientation stage included the needs for decision-making categorised into Information needs and Conversation needs. Women indicated that -if they were to receive sufficient time for Orientation and Deliberation- they would be able to reach the stage of Final decision.

CONCLUSION

The decision-making framework resulting from our findings can be used by health care professionals to provide women with information and consultation in the decision-making process. Future studies should investigate whether the stages of and needs for decision-making can be found across other vaccine-hesitant subgroups and vaccinations.

Development and usability testing of Understanding Stroke, a tailored life-sustaining treatment decision support tool for stroke surrogate decision makers

BACKGROUND

Surrogate decision makers of stroke patients are often unprepared to make critical decisions on life-sustaining treatments. We describe the development process and key features for the Understanding Stroke web-based decision support tool.

METHODS

We used multiple strategies to develop a patient-centered, tailored decision aid. We began by forming a Patient and Family Advisory Council to provide continuous input to our multidisciplinary team on the development of the tool. Additionally, focus groups consisting of nurses, therapists, social workers, physicians, stroke survivors, and family members reviewed key elements of the tool, including prognostic information, graphical displays, and values clarification exercise. To design the values clarification exercise, we asked focus groups to provide feedback on a list of important activities of daily living. An ordinal prognostic model was developed for ischemic stroke and intracerebral hemorrhage using data taken from the Virtual International Stroke Trials Archive Plus, and incorporated into the tool.

RESULTS

Focus group participants recommended making numeric prognostic information optional due to possible emotional distress. Pie charts were generally favored by participants for graphical presentation of prognostic information, though a horizontal stacked bar chart was also added due to its prevalence in stroke literature. Plain language descriptions of the modified Rankin Scale were created to accompany the prognostic information. A values clarification exercise was developed consisting of a list of 13 situations that may make an individual consider comfort measures only. The final version of the web based tool (which can be viewed on tablets) included the following sections: general introduction to stroke, outcomes (prognostic information and recovery), in-hospital and life-sustaining treatments, decision making and values clarification, post-hospital care, tips for talking to the health care team, and a summary report. Preliminary usability testing received generally favorable feedback.

CONCLUSION

We developed Understanding Stroke, a tailored decision support tool for surrogate decision makers of stroke patients. The tool was well received and will be formally pilot tested in a group of stroke surrogate decision makers.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT03427645 ).

What Helps People Make Values-Congruent Medical Decisions? Eleven Strategies Tested across 6 Studies

Background. High-quality health decisions are often defined as those that are both evidence informed and values congruent. A values-congruent decision aligns with what matters to those most affected by the decision. Values clarification methods are intended to support values-congruent decisions, but their effects on values congruence are rarely evaluated. Methods. We tested 11 strategies, including the 3 most commonly used values clarification methods, across 6 between-subjects online randomized experiments in demographically diverse US populations ( n1 = 1346, n2 = 456, n3 = 840, n4 = 1178, n5 = 841, n6 = 2033) in the same hypothetical decision. Our primary outcome was values congruence. Decisional conflict was a secondary outcome in studies 3 to 6. Results. Two commonly used values clarification methods (pros and cons, rating scales) reduced decisional conflict but did not encourage values-congruent decisions. Strategies using mathematical models to show participants which option aligned with what mattered to them encouraged values-congruent decisions and reduced decisional conflict when assessed. Limitations. A hypothetical decision was necessary for ethical reasons, as we believed some strategies may harm decision quality. Later studies used more outcomes and covariates. Results may not generalize outside US-based adults with online access. We assumed validity and stability of values during the brief experiments. Conclusions. Failing to explicitly support the process of aligning options with values leads to increased proportions of values-incongruent decisions. Methods representing more than half of values clarification methods commonly in use failed to encourage values-congruent decisions. Methods that use models to explicitly show people how options align with their values offer more promise for helping people make decisions aligned with what matters to them. Decisional conflict, while arguably an important outcome in and of itself, is not an appropriate proxy for values congruence.

A Values-Tailored Web-Based Intervention for New Mothers to Increase Infant Vaccine Uptake: Development and Qualitative Study

BACKGROUND

Vaccine hesitancy among parents leads to childhood undervaccination and outbreaks of vaccine-preventable disease. As the reasons for vaccine hesitancy are diverse, there is often not enough time during regular clinical visits for medical providers to adequately address all the concerns that parents have. Providing individually tailored vaccine information via the internet before a clinical visit may be a good mechanism for effectively allaying parents' vaccination concerns while also being time efficient. Including tailoring based on values is a promising, but untested, approach to message creation.

OBJECTIVE

This study aimed to describe the process by which we developed a Web-based intervention that is being used in an ongoing randomized controlled trial aimed at improving the timeliness of infant vaccination by reducing parental vaccine hesitancy.

METHODS

Development of the intervention incorporated evidence-based health behavior theories. A series of interviews, surveys, and feedback sessions were used to iteratively develop the intervention in collaboration with vaccination experts and potential end users.

RESULTS

In all, 41 specific content areas were identified to be included in the intervention. User feedback elucidated preferences for specific design elements to be incorporated throughout the website. The tile-based architecture chosen for the website was perceived as easy to use. Creating messages that were two-sided was generally preferred over other message formats. Quantitative surveys identified associations between specific vaccine values and vaccination beliefs, suggesting that values tailoring should vary, depending on the specific belief being endorsed.

CONCLUSIONS

Using health behavior theories, qualitative and quantitative data, and significant expert and end user input, we created a novel, Web-based intervention to improve infant vaccination timeliness. The intervention is based on tailoring messages according to each individual's values and beliefs. This intervention is currently being tested in a controlled randomized clinical trial.

Neuroeconomics, health psychology, and the interdisciplinary study of preventative health behavior

The goal of this article is to introduce readers to theories, tools, and evidence from the field of neuroeconomics and to describe how health psychology and neuroeconomics can be mutually informative in the study of preventative health behaviors. Preventative health behavior here refers to both individual actions that impact one's health (e.g., exercise) and broader behavioral patterns, such as those captured in personality constructs. Although neuroeconomic researchers have begun to incorporate health-relevant behaviors into their studies, the full potential of this research to inform preventative health models is as yet unrealized. What is needed to "translate up" is the unification of rich theoretical content from health psychology with investigations by neuroeconomic researchers of the decision-making process during health-relevant choices. We identify choice as a central, shared feature across models of preventative health behavior that can serve as an inroad for neuroeconomics to contribute to existing models and highlight commonalities that might not otherwise be apparent. A central premise of our argument is that, because health decisions are nearly always multiply determined, a more precise and mechanistic understanding of how choices are made is an important but understudied topic in health psychology. A partnership between health psychologists and neuroeconomic researchers can yield valuable insights into how preventative health choice is made and to identify targets and methods for intervention.

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.

Sharing knowledge about immunisation (SKAI): An exploration of parents' communication needs to inform development of a clinical communication support intervention

INTRODUCTION

The SKAI (Sharing Knowledge About Immunisation) project aims to develop effective communication tools to support primary health care providers' consultations with parents who may be hesitant about vaccinating their children.

AIM

This study explored parents' communication needs using a qualitative design.

METHODS

Parents of at least one child less than five years old were recruited from two major cities and a regional town known for high prevalence of vaccine objection. Focus groups of parents who held similar vaccination attitudes and intentions were convened to discuss experiences of vaccination consultations and explore their communication needs, including preferences. Draft written communication support tools were used to stimulate discussion and gauge acceptability of the tools.

RESULTS

Important differences in communication needs between group types emerged. The least hesitant parent groups reported feeling reassured upon reading resources designed to address commonly observed concerns about vaccination. As hesitancy of the group members increased, so did their accounts of the volume and detail of information they required. Trust appeared to be related to apparent or perceived transparency. More hesitant groups displayed increased sensitivity and resistance to persuasive language forms.

"I don't know exactly what you're referring to": the challenge of values elicitation in decision making for implantable cardioverter-defibrillators

PURPOSE

Patients' values are a key component of patient-centered care and shared decision making in health care organizations. There is limited understanding on how patients' values guide their health related decision making or how patients understand the concept of values during these processes. This study investigated patients' understanding of their values in the context of considering the risks/benefits of receiving an implantable cardioverter-defibrillator (ICD).

PATIENTS AND METHODS

A qualitative substudy was conducted within a feasibility trial with first-time ICD candidates randomized to receive a patient decision aid or usual care prior to specialist consultation. Semi-structured interviews were conducted with participants post-implantation or post-specialist consultation.

RESULTS

Sixteen patients (ten male) aged 47-87 years participated. Of these, ten (62.5%) received the patient decision aid prior to specialist consultation. Findings revealed patients were confused by the word "values" and had difficulty expressing values related to risks/benefits during ICD decision making. When probed, values were conceptualized broadly capturing other factors such as desire to live, good quality of life, family's views, ICD information, control over decision, and medical authority.

CONCLUSION

This study revealed the difficulty patients considering an ICD had with articulating their values in the context of an ICD health decision and highlighted the challenge to effectively elicit patients' values within health decisions overall. It is suggested that there should be a shift away from the use of the word "values" when speaking directly to patients toward language such as "what matters to you the most" or "what is most important to you".

The Role of Risk Perception in Flu Vaccine Behavior among African-American and White Adults in the United States

Seasonal flu vaccination rates are low for U.S. adults, with significant disparities between African and white Americans. Risk perception is a significant predictor of vaccine behavior but the research on this construct has been flawed. This study addressed critical research questions to understand the differences between African and white Americans in the role of risk perception in flu vaccine behavior: (1) What is the dimensionality of risk perception and does it differ between the two races?  (2) Were risk perceptions of white and African-American populations different and how were sociodemographic characteristics related to risk for each group? (3) What is the relation between risk perception and flu vaccine behaviors for African Americans and whites? The sample, drawn from GfK's Knowledge Panel, consisted of 838 whites and 819 African Americans. The survey instrument was developed from qualitative research. Measures of risk perception included cognitive and emotional measures of disease risk and risk of side effects from the vaccine. The online survey was conducted in March 2015. Results showed the importance of risk perception in the vaccine decision-making process for both racial groups. As expected, those who got the vaccine reported higher disease risk than those who did not. Separate cognitive and emotional factors did not materialize in this study but strong evidence was found to support the importance of considering disease risk as well as risk of the vaccine. There were significant racial differences in the way risk perception predicted behavior.

Using campaigns to improve perceptions of the value of adult vaccination in the United States: Health communication considerations and insights

Vaccines have much relevance and promise for improving adult health in the United States, but to date, overall use and uptake remain far below desired levels. Many adults have not received recommended vaccinations and many healthcare providers do not strongly and actively encourage their use with patients. This has led some public health and medical experts to conclude that adult vaccines are severely undervalued by the U.S. public and healthcare providers and to call for campaigns and communication-based efforts to foster increased appreciation, and in turn, higher adult immunization rates. A narrative integrative review that draws upon the vaccine valuation and health communication literatures is used to develop a framework to guide campaign and communication-based efforts to improve public, provider, and policymakers' assessment of the value of adult vaccination. The review does this by: (1) distinguishing social psychological value from economic value; (2) identifying the implications of social psychological value considerations for adult vaccination-related communication campaigns; and (3) using five core health communication considerations to illustrate how social psychological notions of value can be integrated into campaigns or communication that are intended to improve adult vaccination value perceptions and assessments, and in turn, motivate greater support for and uptake of recommended adult vaccines.

Clinical trainees' responses to parents who question evidence-based recommendations

OBJECTIVE

We examined clinicians' attitudes, beliefs, and behavioral intentions about discussing evidence and eliciting values when patients question recommendations.

METHODS

We randomized trainees to read one of three scenarios about a parent of a one-year-old: 1) overuse (parent requests antibiotics for presumed viral infection); 2) equipoise (tubes for recurrent ear infections); 3) underuse (parent hesitates about vaccination). Participants then answered survey questions. Outcomes included time spent clarifying values (primary), attitudes and beliefs about the parent (secondary).

RESULTS

132 medical students and pediatric residents enrolled; 119 (90%) completed the study. There were no differences in time participants would spend clarifying values (antibiotics 26±12%; equipoise 28±11%; vaccine-hesitancy 22±11%; p=0.058). Participants in the vaccine-hesitancy group (vs. other groups) would spend less time answering questions (p=0.006). Participants in the antibiotics (vs. equipoise) group perceived the parent as difficult (p=0.0002). Those in the vaccine-hesitancy group (vs. other groups) perceived the parent as difficult, saw less value in the conversation, and had lower respect for the parent's views (all ps<0.0001). Most (76%) wanted additional training navigating these discussions.

CONCLUSION

Clinicians' attitudes may impact conversations when patients question evidence-based recommendations.

PRACTICE IMPLICATIONS

Clinicians should consider ways to discuss evidence and clarify patients' values to optimize health without damaging patient-clinician relationships.

Communicating infectious disease prevalence through graphics: Results from an international survey

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The impact of graphics to inform the general public on health knowledge is unknown.

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Heat maps were evaluated as superior to dot maps or picto-trendlines.

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Heat maps are a viable option to widely disseminate information about infectious diseases.

Background

Graphics are increasingly used to represent the spread of infectious diseases (e.g., influenza, Zika, Ebola); however, the impact of using graphics to adequately inform the general population is unknown.

Objective

To examine whether three ways of visually presenting data (heat map, dot map, or picto-trendline)—all depicting the same information regarding the spread of a hypothetical outbreak of influenza—influence intent to vaccinate, risk perception, and knowledge.

Design

Survey with participants randomized to receive a simulated news article accompanied by one of the three graphics that communicated prevalence of influenza and number of influenza-related deaths.

Setting

International online survey.

Participants

16,510 adults living in 11 countries selected using stratified random sampling based on age and gender.

Measurements

After reading the article and viewing the presented graphic, participants completed a survey that measured interest in vaccination, perceived risk of contracting disease, knowledge gained, interest in additional information about the disease, and perception of the graphic.

Results

Heat maps and picto-trendlines were evaluated more positively than dot maps. Heat maps were more effective than picto-trendlines and no different from dot maps at increasing interest in vaccination, perceived risk of contracting disease, and interest in additional information about the disease. Heat maps and picto-trendlines were more successful at conveying knowledge than dot maps. Overall, heat maps were the only graphic to be superior in every outcome.

Limitations

Results are based on a hypothetical scenario.

Conclusion

Heat maps are a viable option to promote interest in and concern about infectious diseases.

Negotiating Tensions Between Theory and Design in the Development of Mailings for People Recovering From Acute Coronary Syndrome

Background

Taking all recommended secondary prevention cardiac medications and fully participating in a formal cardiac rehabilitation program significantly reduces mortality and morbidity in the year following a heart attack. However, many people who have had a heart attack stop taking some or all of their recommended medications prematurely and many do not complete a formal cardiac rehabilitation program.

Objective

The objective of our study was to develop a user-centered, theory-based, scalable intervention of printed educational materials to encourage and support people who have had a heart attack to use recommended secondary prevention cardiac treatments.

Methods

Prior to the design process, we conducted theory-based interviews and surveys with patients who had had a heart attack to identify key determinants of secondary prevention behaviors. Our interdisciplinary research team then partnered with a patient advisor and design firm to undertake an iterative, theory-informed, user-centered design process to operationalize techniques to address these determinants. User-centered design requires considering users’ needs, goals, strengths, limitations, context, and intuitive processes; designing prototypes adapted to users accordingly; observing how potential users respond to the prototype; and using those data to refine the design. To accomplish these tasks, we conducted user research to develop personas (archetypes of potential users), developed a preliminary prototype using behavior change theory to map behavior change techniques to identified determinants of medication adherence, and conducted 2 design cycles, testing materials via think-aloud and semistructured interviews with a total of 11 users (10 patients who had experienced a heart attack and 1 caregiver). We recruited participants at a single cardiac clinic using purposive sampling informed by our personas. We recorded sessions with users and extracted key themes from transcripts. We held interdisciplinary team discussions to interpret findings in the context of relevant theory-based evidence and iteratively adapted the intervention accordingly.

Results

Through our iterative development and testing, we identified 3 key tensions: (1) evidence from theory-based studies versus users’ feelings, (2) informative versus persuasive communication, and (3) logistical constraints for the intervention versus users’ desires or preferences. We addressed these by (1) identifying root causes for users’ feelings and addressing those to better incorporate theory- and evidence-based features, (2) accepting that our intervention was ethically justified in being persuasive, and (3) making changes to the intervention where possible, such as attempting to match imagery in the materials to patients’ self-images.

Conclusions

Theory-informed interventions must be operationalized in ways that fit with user needs. Tensions between users’ desires or preferences and health care system goals and constraints must be identified and addressed to the greatest extent possible. A cluster randomized controlled trial of the final intervention is currently underway.

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.

Understanding Vaccine Hesitancy in Canada: Results of a Consultation Study by the Canadian Immunization Research Network

"Vaccine hesitancy" is a concept now frequently used in vaccination discourse. The increased popularity of this concept in both academic and public health circles is challenging previously held perspectives that individual vaccination attitudes and behaviours are a simple dichotomy of accept or reject. A consultation study was designed to assess the opinions of experts and health professionals concerning the definition, scope, and causes of vaccine hesitancy in Canada. We sent online surveys to two panels (1- vaccination experts and 2- front-line vaccine providers). Two questionnaires were completed by each panel, with data from the first questionnaire informing the development of questions for the second. Our participants defined vaccine hesitancy as an attitude (doubts, concerns) as well as a behaviour (refusing some / many vaccines, delaying vaccination). Our findings also indicate that both vaccine experts and front-line vaccine providers have the perception that vaccine rates have been declining and consider vaccine hesitancy an important issue to address in Canada. Diffusion of negative information online and lack of knowledge about vaccines were identified as the key causes of vaccine hesitancy by the participants. A common understanding of vaccine hesitancy among researchers, public health experts, policymakers and health care providers will better guide interventions that can more effectively address vaccine hesitancy within Canada.

Can the vaccine adverse event reporting system be used to increase vaccine acceptance and trust?

Vaccine refusal has an impact on public health, and the human pappillomavirus (HPV) vaccine is particularly underutilized. Research suggests that it may be difficult to change vaccine-related attitudes, and there is currently no good evidence to recommend any particular intervention strategy. One reason for vaccine hesitancy is lack of trust that vaccine harms are adequately documented and reported, yet few communication strategies have explicitly attempted to improve this trust. This study tested the possibility that data from the vaccine adverse event reporting system (VAERS) can be used to increase trust that vaccine harms are adequately researched and that potential harms are disclosed to the public, and thereby improve perceptions of vaccines. In the study, participants were randomly assigned to one of three communication interventions. All participants read the Centers for Disease Control (CDC) vaccine information statement (VIS) for the HPV vaccine. Two other groups were exposed to additional information about VAERS, either summary data or full detailed reports of serious adverse events from 2013. Results showed that the CDC's VIS alone significantly increased perceptions of vaccine benefits and decreased perceived risks. Participants who were also educated about VAERS and given summary data about the serious adverse events displayed more trust in the CDC and greater HPV vaccine acceptance relative to the VIS alone. However, exposure to the detailed VAERS reports significantly reduced trust in the CDC and vaccine acceptance. Hence, general information about the VAERS data slightly increased trust in the CDC and improved vaccine acceptance, but the specific VAERS reports negatively influenced both trust and acceptance. Implications for communicating about vaccines are discussed.