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

A systematic literature review of human papillomavirus vaccination strategies in delivery systems within national and regional immunization programs

The uptake of human papillomavirus (HPV) vaccine remains suboptimal despite being a part of routine vaccination within national immunization program(s). This indicates probable challenges with the implementation of HPV immunization program(s) in various countries. The objective of this systematic literature review (SLR) was to identify implementation strategies for HPV vaccination within national and regional immunization programs worldwide with an aim to provide guidance for countries targeting to increase their HPV vaccine coverage rate (VCR). A comprehensive literature search was conducted across Medline and Embase and included articles published between January 2012 and January 2022. Of the 2,549 articles retrieved, 168 met inclusion criteria and were included in the review. Strategies shown to improve HPV vaccination uptake in the reviewed literature include campaigns to increase community awareness and knowledge of HPV, health care provider trainings, integrating HPV vaccination within school settings, coordinated efforts via multi-sectoral partnerships, and vaccination reminder and recall systems. Findings may help national authorities understand key considerations for HPV vaccination when designing and implementing programs aiming to increase HPV VCR in adolescents.

Interventions to increase vaccination in vulnerable groups: rapid overview of reviews

OBJECTIVE

Groups which are marginalised, disadvantaged or otherwise vulnerable have lower uptake of vaccinations. This differential has been amplified in COVID-19 vaccination compared to (e.g.) influenza vaccination. This overview assessed the effectiveness of interventions to increase vaccination in underserved, minority or vulnerable groups.

METHODS

In November 2022 we searched four databases for systematic reviews that included RCTs evaluating any intervention to increase vaccination in underserved, minority or vulnerable groups; our primary outcome was vaccination. We used rapid review methods to screen, extract data and assess risk of bias in identified reviews. We undertook narrative synthesis using an approach modified from SWiM guidance. We categorised interventions as being high, medium or low intensity, and as targeting vaccine demand, access, or providers.

RESULTS

We included 23 systematic reviews, including studies in high and low or middle income countries, focused on children, adolescents and adults. Groups were vulnerable based on socioeconomic status, minority ethnicity, migrant/refugee status, age, location or LGBTQ identity. Pregnancy/maternity sometimes intersected with vulnerabilities. Evidence supported interventions including: home visits to communicate/educate and to vaccinate, and facilitator visits to practices (high intensity); telephone calls to communicate/educate, remind/book appointments (medium intensity); letters, postcards or text messages to communicate/educate, remind/book appointments and reminder/recall interventions for practices (low intensity). Many studies used multiple interventions or components.

CONCLUSION

There was considerable evidence supporting the effectiveness of communication in person, by phone or in writing to increase vaccination. Both high and low intensity interventions targeting providers showed effectiveness. Limited evidence assessed additional clinics or targeted services for increasing access; only home visits had higher confidence evidence showing effectiveness. There was no evidence for interventions for some communities, such as religious minorities which may intersect with gaps in evidence for additional services. None of the evidence related to COVID-19 vaccination where inequalities of outcome are exacerbated.

PROSPERO REGISTRATION

CRD42021293355.

Determinants of non-vaccination against seasonal influenza during pregnancy

OBJECTIVE

The objective of this study was to identify the determinants of influenza non-vaccination during pregnancy in Canada.

METHODS

Biological mothers of children born between December 2018 and March 2019 were surveyed about vaccinations they had received during pregnancy, reasons for non-vaccination, obstetrical history, and demographics. Simple and multiple logistic regression models were used to measure associations between various sociodemographic factors as well as obstetrical history, and non-vaccination against influenza. We analyzed data from 2361 mothers.

RESULTS

Factors associated with non-vaccination included being followed during pregnancy by a midwife compared to by an obstetrician-gynecologist (OR 2.02; 95% CI, 1.17‒3.50); having two or more past live births compared to none (OR 1.58; 95% CI, 1.01‒2.49); having an education level below high school diploma compared to a bachelor's degree or above (OR 2.50; 95% CI, 1.06‒5.90); and having a household income below $60,000 (OR 2.46; 95% CI, 1.42‒4.24) or between $60,000 and $99,999 (OR 2.77; 95% CI, 1.70‒4.52) compared to a household income of $140,000 or more. The province or territory of prenatal care proved to be an important factor in non-vaccination, with statistically significant odds ratios for certain provinces: OR 7.50 (95% CI, 1.40‒40.26) for Ontario, 8.23 (95% CI, 1.53‒44.23) for Newfoundland and Labrador, and 11.39 (95% CI, 2.14‒60.60) for Quebec, as compared to the territories.

CONCLUSION

Despite universal access to influenza vaccines in Canada during pregnancy, regional variations and socioeconomic disparities in non-vaccination are still observable.

Factors associated with COVID-19 vaccine uptake among health professionals in Debre Markos town public health facilities, Northwest Ethiopia

Globally, the COVID-19 pandemic has significantly increased morbidity and mortality. Health professionals are at the frontline of COVID-19 pandemic exposure and are identified as a priority target group that needs to receive COVID-19 vaccines. Data on Ethiopian healthcare workers' use of the COVID-19 vaccine and associated factors, however, are scarce. Using a simple random sampling method, 398 health professionals were recruited through an institutional-based cross-sectional study design. Health professionals working in Debre Markos town public health facilities filled out a self-administered questionnaire that had been pretested to obtain the data. Then, the data were entered into Epi data version 4.2; and analyzed by SPSS 25. Descriptive statistics and multivariable logistic regression analysis were computed after model assumptions were checked. The adjusted odds ratio with 95% CI was calculated and statistical significance was declared at P-value < 0.05 after model adequacy was checked using the Hosmer-Lemeshow test. The uptake of the COVID-19 vaccine among health professionals was 61.56% (95% CI: 56.67%, 66.23%). Factors associated with the uptake of the COVID-19 vaccine were age > = 35 years (AOR: 4.39, 95% CI: 1.89, 10.19), having a higher income (>9056 Birr) (AOR: 1.79, 95% CI: 1.03, 3.10), who practiced COVID-19 Prevention methods (AOR: 2.39, 95% CI: 1.51, 3.77), Adulthood previous other immunization histories (AOR: 1.63, 95% CI: 1.15, 2.56) and having a chronic disease (AOR:1.90,95% CI: 1.07, 3.74). This study revealed that the uptake of the COVID-19 vaccine was low. Age > = 35 years, having a higher income, who practiced COVID-19 prevention methods, having adulthood previous immunization histories, and having chronic disease were statistically significantly identified factors for COVID-19 vaccine uptake. Therefore, policymakers and health managers should think about the requirement of immunization of healthcare workers and develop plans for administering the COVID-19 vaccine.

A Low-Cost, Integrated Immunization, Health, and Nutrition Intervention in Conflict Settings in Pakistan-The Impact on Zero-Dose Children and Polio Coverage

Pakistan is one of two countries globally still endemic for poliovirus. While increasing immunization coverage is a concern, providing equitable access to care is also a priority, especially for conflict-affected populations. Recognizing these challenges, Naunehal, an integrated model of maternal, newborn, and child health (MNCH), immunization, and nutrition services delivered through community mobilization, mobile outreach, and private-sector engagement was implemented in conflict-affected union councils (UCs) with high poliovirus transmission, including Kharotabad 1(Quetta, Balochistan) and Bakhmal Ahmedzai (Lakki Marwat, Khyber Pakhtunkhwa). A quasi-experimental pre-post-design was used to assess the impact of the interventions implemented between April 2021 and April 2022, with a baseline and an endline survey. For each of the intervention UCs, a separate, matched-control UC was identified. At endline, the proportion of fully immunized children increased significantly from 27.5% to 51.0% in intervention UCs with a difference-in-difference (DiD) estimate of 13.6%. The proportion of zero-dose children and non-recipients of routine immunization (NR-RI) children decreased from 31.6% to 0.9% and from 31.9% to 3.4%, respectively, with a significant decrease in the latter group. Scaling up and assessing the adoption and feasibility of integrated interventions to improve immunization coverage can inform policymakers of the viability of such services in such contexts.

Increasing vaccinations through an on-site school-based education and vaccination program: A city-wide cluster randomized controlled trial

Vaccination rates for mumps, measles, and rubella (MMR) and tetanus, diphtheria, pertussis, and polio (Tdap-IPV) fall short of global targets, highlighting the need for vaccination interventions. This study examines the effectiveness of a city-wide school-based educational vaccination intervention as part of an on-site vaccination program aimed at increasing MMR and Tdap-IPV vaccination rates versus on-site vaccination alone among sociodemographically diverse students from Berlin, Germany. The study was a 1:1 two-arm cluster randomized controlled trial, with schools randomly assigned to either the Educational Class Condition (ECC) or the Low-Intensity Information Condition (LIIC). Both received an on-site vaccination program, while students in the ECC received an additional educational unit. Primary outcomes were MMR and Tdap-IPV vaccination rates. In total, 6512 students from 25 randomly selected urban area secondary schools participated. For students providing their vaccination documents on the day of the intervention (2273, 34.9%), adjusted Poisson mixed models revealed significant between-group differences in favor of the ECC (MMR: logRR = 0.47, 95%CI [0.01,0.92], RR = 1.59; Tdap-IPV: logRR = 0.28, 95%CI [0.10,0.47], RR = 1.32). When adjusting for socioeconomic and migration background, between-group differences became non-significant for MMR but remained significant for Tdap-IPV. Findings suggest that educational, school-based on-site vaccination appears to be a promising strategy for increasing vaccination uptake in adolescents.

Learning from the universal, proactive outreach of the Brazilian Community Health Worker model: impact of a Community Health and Wellbeing Worker initiative on vaccination, cancer screening and NHS health check uptake in a deprived community in the UK

BACKGROUND

Delays in preventative service uptake are increasing in the UK. Universal, comprehensive monthly outreach by Community Health and Wellbeing Workers (CHW), who are integrated at the GP practice and local authority, offer a promising alternative to general public health campaigns as it personalises health promotion and prevention of disease holistically at the household level. We sought to test the ability of this model, which is based on the Brazilian Family Health Strategy, to increase prevention uptake in the UK.

METHODS

Analysis of primary care patient records for 662 households that were allocated to five CHWWs from July 2021. Primary outcome was the Composite Referral Completion Indicator (CRCI), a measure of how many health promotion activities were received by members of a household relative to the ones that they were eligible for during the period July 2021-April 2022. The CRCI was compared between the intervention group (those who had received at least one visit) and the control group (allocated households that were yet to receive a visit). A secondary outcome was the number of GP visits in the intervention and control groups during the study period and compared to a year prior.

RESULTS

Intervention and control groups were largely comparable in terms of household occupancy and service eligibilities. A total of 2251 patients in 662 corresponding households were allocated to 5 CHWs and 160 households had received at least one visit during the intervention period. The remaining households were included in the control group. Overall service uptake was 40% higher in the intervention group compared to control group (CRCI: 0.21 ± 0.15 and 0.15 ± 0.19 respectively). Likelihood of immunisation uptake specifically was 47% higher and cancer screening and NHS Health Checks was 82% higher. The average number of GP consultations per household decreased by 7.4% in the intervention group over the first 10 months of the pilot compared to the 10 months preceding its start, compared with a 0.6% decrease in the control group.

CONCLUSIONS

Despite the short study period these are promising findings in this deprived, traditionally hard to reach community and demonstrates potential for the Brazilian community health worker model to be impactful in the UK. Further analysis is needed to examine if this approach can reduce health inequalities and increase cost effectiveness of health promotion approaches.

Effectiveness of a vaccine recovery plan after the COVID-19 pandemic in the Siracusa Local Health Authority, Italy. Results of one year follow-up

Introduction

The COVID-19 pandemic has strongly impacted on the immunization services around the world, threatening the gains made in the control of vaccine-preventable diseases.

Methods

A vaccination recovery plan of missed vaccinations has been put in place in the LHA of Siracusa after the pandemic. We compared 2021 and 2020 vaccination coverage by age group and vaccine type after one year of follow-up of the recovery plan. The Chi-square test was executed on proportions for the years 2021 vs 2020. Results were considered statistically significant at a two-tailed p-value ≤ 0.05.

Results

36-month coverage rates were 92.5% for polio and 93.7% for measles-containing-vaccine, representing -0.3% and -1.8% decreases, respectively, as compared to 2020. By 8 years of age (booster doses), immunisation coverage was 80.7% for polio and 80.1% for measles, representing a -5.7% and -3.7%, respectively, compared to 2020. 36-month coverage was 56.6% for Men B (-5.0% as compared to 2020), 73.2% for Men ACW135Y/C (+1.1% as compared to 2020) and 86.9% for PNC vaccine (-1.7%, as compared to 2020). Regarding HPV vaccination, in 2021, vaccine coverage was 44.2% (-4.4% compared to 2020). Compared to the previous report, the VC difference among the cohorts narrowed for all almost vaccinations, except for the anti-men B and the anti-HPV vaccination, for which we recorded an increase in VC difference, and for men ACW135Y/C, for which a significant increase has been recorded.

Conclusions

Despite the efforts to organize and realize an extensive and well-designed vaccination recovery, our data show that even after the 1-year follow-up, globally deficits in coverage for these routine vaccinations persist, although there has been a substantial and significant recovery of missed vaccinations, especially among younger children and for primary cycles.

Addressing Determinants of Immunization Inequities Requires Objective Tools to Devise Local Solutions

Universal immunization substantially reduces morbidity and mortality from vaccine-preventable diseases. In recent years, routine immunization coverage has varied considerably among countries across the WHO European Region, and among different populations and districts within countries. It has even declined in some countries. Sub-optimal immunization coverage contributes to accumulations of susceptible individuals and can lead to outbreaks of vaccine-preventable diseases. The European Immunization Agenda 2030 (EIA2030) seeks to build better health in the WHO European Region by ensuring equity in immunization and supporting immunization stakeholders in devising local solutions to local challenges. The factors that influence routine immunization uptake are context specific and multifactorial; addressing immunization inequities will require overcoming or removing barriers to vaccination for underserved individuals or populations. Local level immunization stakeholders must first identify the underlying causes of inequities, and based on this information, tailor resources, or service provision to the local context, as per the organization and characteristics of the health care system in their countries. To do this, in addition to using the tools already available to broadly identify immunization inequities at the national and regional levels, they will need new pragmatic guidance and tools to address the identified local challenges. It is time to develop the necessary guidance and tools and support immunization stakeholders at all levels, especially those at the subnational or local health centre levels, to make the vision of EIA2030 a reality.

Mapping sociodemographic and geographical differences in human papillomavirus non-vaccination among young girls in Sweden

AIMS

Human papillomavirus (HPV) vaccination plays a key role in the prevention of cervical cancer. Yet, disparities in HPV vaccination in Sweden have persisted. Previous research on such disparities has typically focused on singular sociodemographic variables and measures of average risk. Using a multi-categorical approach and drawing on intersectionality theory, this study aimed to provide a more precise mapping of HPV non-vaccination among girls in different sociodemographic groups and geographical areas in Sweden during 2013-2020.

METHODS

Using nationwide register data, we conducted a multi-categorical analysis of individual heterogeneity and discriminatory accuracy complemented by a multilevel geographical analysis. We mapped HPV non-vaccination prevalence across 54 strata defined by parental income, education and country of birth, and urban versus rural place of residence. We also disentangled municipal and regional influences on HPV non-vaccination.

RESULTS

HPV non-vaccination was more common in groups with a low income, a low education and an immigration background, whereas among those with an immigration background, the association between income, education and HPV non-vaccination was more complex. Geographical differences were found between municipalities. However, the discriminatory accuracy of the sociodemographic and geographical groups was weak, and 50% of the non-vaccination cases were observed in eight strata, of which some are among those with low risk.

CONCLUSIONS

Our findings underscore the importance of universal yet tailored approaches, including providing adequate information about HPV vaccination in Swedish and other languages, and of health-care professionals displaying sensitivity to patients' and parents' questions or needs.

Implementation of a quality improvement programme using the Active Patient Link call and recall system to improve timeliness and equity of childhood vaccinations: protocol for a mixed-methods evaluation

INTRODUCTION

Call and recall systems provide actionable intelligence to improve equity and timeliness of childhood vaccinations, which have been disrupted during the COVID-19 pandemic. We will evaluate the effectiveness, fidelity and sustainability of a data-enabled quality improvement programme delivered in primary care using an Active Patient Link Immunisation (APL-Imms) call and recall system to improve timeliness and equity of uptake in a multiethnic disadvantaged urban population. We will use qualitative methods to evaluate programme delivery, focusing on uptake and use, implementation barriers and service improvements for clinical and non-clinical primary care staff, its fidelity and sustainability.

METHODS AND ANALYSIS

This is a mixed-methods observational study in 284 general practices in north east London (NEL). The target population will be preschool-aged children eligible to receive diphtheria, tetanus and pertussis (DTaP) or measles, mumps and rubella (MMR) vaccinations and registered with an NEL general practice. The intervention comprises an in-practice call and recall tool, facilitation and training, and financial incentives. The quantitative evaluation will include interrupted time Series analyses and Slope Index of Inequality. The primary outcomes will be the proportion of children receiving at least one dose of a DTaP-containing or MMR vaccination defined, respectively, as administered between age 6 weeks and 6 months or between 12 and 18 months of age. The qualitative evaluation will involve a 'Think Aloud' method and semistructured interviews of stakeholders to assess impact, fidelity and sustainability of the APL-Imms tool, and fidelity of the implementation by facilitators.

ETHICS AND DISSEMINATION

The research team has been granted permission from data controllers in participating practices to use deidentified data for audit purposes. As findings will be specific to the local context, research ethics approval is not required. Results will be disseminated in a peer-reviewed journal and to stakeholders, including parents, health providers and commissioners.

Widening Disparities in Teen HPV Vaccinations during COVID-19 Pandemic: A Case Study from Veneto Region (Italy)

INTRODUCTION

In Local Health Unit 7, human papilloma virus (HPV) vaccination campaigns for 12-year-olds have long been implemented by the vaccination services of the Department of Prevention. Due to the pressure of the COVID-19 pandemic on these services, an emergency vaccination campaign was directly managed by primary care pediatricians (PCPs). An initial evaluation of this experience was conducted.

MATERIALS AND METHODS

Data on 12-year-olds assisted by PCPs belonging to the 2006 (pre-pandemic) and 2008 (pandemic) birth cohorts were extracted, along with HPV vaccination data. Health district, gender, citizenship, socioeconomic status, and PCPs were evaluated as possible influencing factors in a two-level logistic regression (second level: single PCP).

RESULTS

The HPV vaccination gap between males and females increased significantly for the 2008 birth cohort compared to the 2006 birth cohort (11 vs. 4 percentage points). As for PCPs, the vaccination uptake range was 4-71% for the 2008 birth cohort vs. 32-85% for the 2006 cohort. The proportion of variance explained at the second level was overall equal to 9.7% for the 2008 cohort vs. 3.6% for the 2006 cohort.

CONCLUSIONS

The vaccination campaign carried out during the peak of the COVID-19 pandemic increased the HPV vaccination gaps among Health Districts, genders, and individual PCPs, probably due to a lack of homogeneity in professional practices and attitudes toward HPV vaccination. Catch-up interventions are required in the immediate term, while an equity-lens approach should be taken for reprogramming the vaccination campaign. Greater involvement of schools and families could ensure a more equitable approach and a better uptake.

Childhood immunization coverage during the COVID-19 pandemic in the province of Siracusa, Italy

Introduction

The COVID-19 pandemic has severely impacted routine immunization activities and a decline in vaccination coverage has been documented around the world. The aim of this study was to assess the impact of the direct and indirect effects of the COVID-19 pandemic on routine childhood vaccination coverage in the Province of Siracusa, Italy.

Methods

We compared 2020 and 2019 vaccination coverage by age group and vaccine type. Results were considered statistically significant at a two-tailed p-value ≤ 0.05.

Results

Our findings show that vaccination coverage rates for mandatory and recommended vaccinations decreased in 2020 compared with the previous year (range from -1.4% to -7.8%). Anti-rotavirus vaccination increased (+4.8%, as compared to 2019), while the reductions observed for polio vaccination (hexavalent) and human papillomavirus vaccination in males were not statistically significant. The reduction did not hit the population in the same manner, with the greater decreases observed for children aged > 24 months compared to the younger (-5.7% vs -2.2%) and for booster doses compared to the primary vaccinations (-6.4% vs -2.6%).

Conclusions

This study found that vaccination coverage of routine childhood immunisations was negatively affected during the COVID-19 pandemic in the Province of Siracusa. It is of huge importance to put in place some catch-up programs to ensure vaccinations at the earliest of individuals who missed immunization during the pandemic.

Levelling up health: A practical, evidence-based framework for reducing health inequalities

There are substantial inequalities in health across society which have been exacerbated by the COVID-19 pandemic. The UK government have committed to a programme of levelling-up to address geographical inequalities. Here we undertake rapid review of the evidence base on interventions to reduce such health inequalities and developed a practical, evidence-based framework to 'level up' health across the country. This paper overviews a rapid review undertaken to develop a framework of guiding principles to guide policy. To that end and based on an initial theory, we searched one electrotonic database (MEDLINE) from 2007 to July 2021 to identify published umbrella reviews and undertook an internet search to identify relevant systematic reviews, primary studies, and grey literature. Titles and abstracts were screened according to the eligibility criteria. Key themes were extracted from the included studies and synthesised into an overarching framework of guiding principles in consultation with an expert panel. Included studies were cross checked with the initial theoretical domains and further searching undertaken to fill any gaps. We identified 16 published umbrella reviews (covering 667 individual studies), 19 grey literature publications, and 15 key systematic reviews or primary studies. Based on these studies, we develop a framework applicable at national, regional and local level which consisted of five principles - 1) healthy-by-default and easy to use initiatives; 2) long-term, multi-sector action; 3) locally designed focus; 4) targeting disadvantaged communities; and 5) matching of resources to need. Decision-makers working on policies to level up health should be guided by these five principles.

Access to Vaccination among Disadvantaged, Isolated and Difficult-to-Reach Communities in the WHO European Region: A Systematic Review

Vaccination has a significant impact on morbidity and mortality. High vaccination coverage rates are required to achieve herd protection against vaccine-preventable diseases. However, limited vaccine access and hesitancy among specific communities represent significant obstacles to this goal. This review provides an overview of critical factors associated with vaccination among disadvantaged groups in World Health Organisation European countries. Initial searches yielded 18,109 publications from four databases, and 104 studies from 19 out of 53 countries reporting 22 vaccine-preventable diseases were included. Nine groups representing the populations of interest were identified, and most of the studies focused on asylum seekers, refugees, migrants and deprived communities. Recall of previous vaccinations received was poor, and serology was conducted in some cases to confirm protection for those who received prior vaccinations. Vaccination coverage was lower among study populations compared to the general population or national average. Factors that influenced uptake, which presented differently at different population levels, included health service accessibility, language and vaccine literacy, including risk perception, disease severity and vaccination benefits. Strategies that could be implemented in vaccination policy and programs were also identified. Overall, interventions specific to target communities are vital to improving uptake. More innovative strategies need to be deployed to improve vaccination coverage among disadvantaged groups.

Using human-centred design to tackle COVID-19 vaccine hesitancy for children and youth: a protocol for a mixed-methods study in Montreal, Canada

INTRODUCTION

To successfully combat COVID-19 vaccine hesitancy and increase uptake, research has demonstrated that interventions are most effective when tailored to meet local needs through active engagement and co-development with communities. This mixed-methods project uses a human-centred design (HCD) approach to understand local perspectives of COVID-19 vaccine hesitancy and develop strategies to enhance vaccine confidence for children and adolescents.

METHODS AND ANALYSIS

Project ECHO (Étude Communautaire sur l'Hésitation vaccinale contre la COVID-19) combines population-based surveys of parents and adolescents with community-based participatory action research to design and pilot strategies to enhance COVID-19 vaccine confidence in two underserved and ethnoculturally diverse neighbourhoods of Montreal, Canada. Two surveys conducted 6 months apart through primary and secondary schools are used to monitor vaccine acceptance and its social determinants among children and youth. Analyses of survey data include descriptive and inferential statistical approaches. Community-led design teams of parents and youth from the two participating neighbourhoods, supported by academic researchers, design thinking experts and community partners, use an HCD approach to: (1) gather data to understand COVID-19 vaccine decision-making among parents and youth in their community and frame a design challenge (inspiration phase); (2) develop an intervention to address the design challenge (ideation phase) and (3) pilot the intervention (implementation phase). Strategies to evaluate the community-led interventions will be co-developed during the implementation phase.

ETHICS AND DISSEMINATION

This study has been approved by the research ethics boards of the Sainte-Justine University Hospital Centre and the University of Montreal. Community design teams will be involved in the dissemination of findings and the design of knowledge translation initiatives that foster dialogue related to COVID-19 vaccination for children and adolescents among community, school and public health stakeholders. Findings will be disseminated through peer-reviewed publications, conference presentations, community forums, policy briefs, and social media content.

When Science Becomes Embroiled in Conflict: Recognizing the Public's Need for Debate while Combating Conspiracies and Misinformation

Most democracies seek input from scientists to inform policies. This can put scientists in a position of intense scrutiny. Here we focus on situations in which scientific evidence conflicts with people's worldviews, preferences, or vested interests. These conflicts frequently play out through systematic dissemination of disinformation or the spreading of conspiracy theories, which may undermine the public's trust in the work of scientists, muddy the waters of what constitutes truth, and may prevent policy from being informed by the best available evidence. However, there are also instances in which public opposition arises from legitimate value judgments and lived experiences. In this article, we analyze the differences between politically-motivated science denial on the one hand, and justifiable public opposition on the other. We conclude with a set of recommendations on tackling misinformation and understanding the public's lived experiences to preserve legitimate democratic debate of policy.

An Analysis of the Willingness to the COVID-19 Vaccine Booster Shots among Urban Employees: Evidence from a Megacity H in Eastern China

Many studies have shown that urban workers may have a higher acceptance rate of coronavirus disease (COVID-19) vaccine uptake compared to their rural counterparts. As Omicron spreads globally, the COVID-19 booster vaccination has been acknowledged as the primary strategy against this variant. In this study, we identify factors related to the willingness of workers in megacities to take the vaccine booster shots and their main reasons accounting for their booster willingness. This research survey was conducted in megacity H in eastern China, and a total of 1227 employees from different industries were interviewed. The study at hand examines the relationship between various characteristics (including both economic and non-economic factors) of urban employees and their intention/desire to accept the COVID-19 booster shoots. The survey results show that some characteristics, namely work organization, vaccine knowledge, and social network, affect their intention to take COVID-19 vaccine booster shots. Urban employees with a strong work organization, a high degree of vaccine knowledge, and a dense social capital are more likely to receive booster injections than other employees. Therefore, work organization, vaccine knowledge, and social networks provide fundamental entry points for designing enhanced injection strategies to increase the acceptance of COVID-19 vaccines among employees in megacities.

COVID-19 Vaccine Uptake among Younger Women in Rural Australia

Vaccine uptake in younger Australian women living in rural and regional communities is poorly understood. This research explored factors affecting their decision making in the context of social determinants of health. A mixed methods design applying an explanatory sequential approach commenced with an online questionnaire followed by in-depth interviews with a sample of the same participants. The majority (56%) of participants indicated a positive intention to be vaccinated against COVID-19, but a substantially high proportion (44%) were uncertain or had no intention to be vaccinated. Significant factors affecting vaccine uptake included inadequate and sometimes misleading information leading to poor perceptions of vaccine safety. The personal benefits of vaccination-such as reduced social restrictions and increased mobility-were perceived more positively than health benefits. Additionally, access issues created a structural barrier affecting uptake among those with positive or uncertain vaccination intentions. Understanding factors affecting vaccine uptake allows for more targeted, equitable and effective vaccination campaigns, essential given the importance of widespread COVID-19 vaccination coverage for public health. The population insights emerging from the study hold lessons and relevance for rural and female populations globally.

Social inequalities in COVID-19 vaccine acceptance and uptake for children and adolescents in Montreal, Canada

Background

The success of current and prospective COVID-19 vaccine campaigns for children and adolescents will in part depend on the willingness of parents to accept vaccination. This study examined social determinants of parental COVID-19 vaccine acceptance and uptake for children and adolescents.

Methods

We used cross-sectional data from an ongoing COVID-19 cohort study in Montreal, Canada and included all parents of 2 to 18-year-olds who completed an online questionnaire between May 18 and June 26, 2021 (n = 809). We calculated child age-adjusted prevalence estimates of vaccine acceptance by parental education, race/ethnicity, birthplace, household income, and neighbourhood, and used multinomial logistic regression to estimate adjusted prevalence differences (aPD) and ratios (aPR). Social determinants of vaccine uptake were examined for the vaccine-eligible sample of 12 to 18 year-olds (n = 306).

Results

Intention to vaccinate children against COVID-19 was high, with only 12.4% of parents unlikely to have their child vaccinated. Parents with younger children were less likely to accept vaccination, as were those from lower-income households, racialized groups, and those born outside Canada. Children from households with annual incomes <$100,000 had 18.4 percent lower prevalence of being vaccinated/very likely vaccinated compared to household incomes ≥$150,000 (95% CI: 10.1 to 26.7). Racialized parents reported greater unwillingness to vaccinate vs. White parents (aPD = 10.3; 95% CI: 1.5, 19.1). Vaccine-eligible adolescents from the most deprived neighbourhood were half as likely to be vaccinated compared to those from the least deprived neighbourhood (aPR = 0.48; 95% CI: 0.18 to 0.77).

Interpretation.

This study identified marked social inequalities in COVID-19 vaccine acceptance and uptake for children and adolescents. Efforts are needed to reach disadvantaged and marginalized populations with tailored strategies that promote informed decision making and facilitate access to vaccination.

Parents' attitudes toward children's vaccination as a marker of trust in health systems

Children's vaccination is a major goal in health-care systems worldwide; nevertheless, disparities in vaccination coverage expose socio-demographic accessibility gaps, unawareness, physicians' disapproval and parents' incomplete adherence reflecting insufficient public-provider trust. Our goal was to analyze parents' attitude toward children's vaccination in correlation with trust among stakeholders. A total of 1031 parents replied to a "snowball" questionnaire; 72% reported high trust in their physician, 42% trusted the authorities, 11% trusted internet groups. Among minorities, parents who fully vaccinate their children were younger, live in urban areas, eat all kinds of foods and trust the authorities, similar to the general population. Low adherence to children's vaccination was correlated with trusting internet groups. Females complied significantly more to child vaccination, although in our study mothers were more highly educated and trusted authorities more than males. The results enable to draw a profile of the "vaccination compliant parent" (with an academic degree, young, urban, eats all kinds of foods, uses conservative medicine). Trust is a major factor influencing vaccination, yet external forces such as community voices, social trends and opinions of religious leaders may play a role in vaccination adherence, beyond personal beliefs, individual habits and self-care. In Israel, education and "healthy behavior" perception alongside generous coverage encourage most parents to comply with the routine vaccination program. In the shade of pandemic outbreaks, we suggest a social-determinant transparent approach to encourage parents to vaccinate their children. Social and religious leaders can pose as agents of change, especially in the case of less educated parents.

Childhood vaccination coverage in Australia: an equity perspective

BACKGROUND

This study describes trends in social inequities in first dose measles-mumps-rubella (MMR1) vaccination coverage in Western Australia (WA) and New South Wales (NSW). Using probabilistically-linked administrative data for 1.2 million children born between 2002 and 2011, we compared levels and trends in MMR1 vaccination coverage measured at age 24 months by maternal country of birth, Aboriginal status, maternal age at delivery, socio-economic status, and remoteness in two states.

RESULTS

Vaccination coverage was 3-4% points lower among children of mothers who gave birth before the age of 20 years, mothers born overseas, mothers with an Aboriginal background, and parents with a low socio-economic status compared to children that did not belong to these social groups. In both states, between 2007 and 2011 there was a decline of 2.1% points in MMR1 vaccination coverage for children whose mothers were born overseas. In 2011, WA had lower coverage among the Aboriginal population (89.5%) and children of young mothers (89.3%) compared to NSW (92.2 and 92.1% respectively).

CONCLUSION

Despite overall high coverage of MMR1 vaccination, coverage inequalities increased especially for children of mothers born overseas. Strategic immunisation plans and policy interventions are important for equitable vaccination levels. Future policy should target children of mothers born overseas and Aboriginal children.

Influence of commissioned provider type and deprivation score on uptake of the childhood flu immunization

BACKGROUND

Since 2015/16 the UK seasonal influenza immunization programme has included children aged 5 and 6 years. In the South West of England school-based providers, GPs or community pharmacies were commissioned to deliver the vaccine depending on the locality. We aimed to assess variation in vaccine uptake in relation to the type of commissioned provider, and levels of socioeconomic deprivation.

METHODS

Data from the South West of England (2015-16 season) were analysed using multilevel logistic regression to assess variation in vaccine uptake by type of commissioned provider, allowing for clustering of children within delivery sites.

RESULTS

Overall uptake in 5 and 6 year olds was 34.3% (37 555/109 404). Vaccine uptake was highest when commissioned through school-based programmes 50.2% (9983/19 867) and lowest when commissioned through pharmacies, 23.1% (4269/18 479). Delivery through schools resulted in less variation by site and equal uptake across age groups, in contrast to GP and pharmacy delivery for which uptake was lower among 6 year olds. Vaccine uptake decreased with increasing levels of deprivation across all types of commissioned provider.

CONCLUSION

School-based programmes achieve the highest and most consistent rates of childhood influenza vaccination. Interventions are still needed to promote more equitable uptake of the childhood influenza vaccine.

Measuring the effectiveness of catch-up MMR delivered by school nurses compared to signposting to general practice on improving MMR coverage

BACKGROUND

This study assesses whether increased coverage of the measles, mumps and rubella (MMR) vaccination differs between areas where school nurses deliver catch-up MMR doses to adolescents in school settings, compared to signposting to general practice.

METHODS

A retrospective cohort study was conducted using Child Health Information Services records within the NHS England South (South Central) commissioning boundary. The sample population included children born 1 September 2000-31 August 2001, in school year 9 during the 2014-15 academic year.

RESULTS

The primary outcome findings show an increase in coverage of at least one dose of MMR by 1.6% (n = 334) in the cohort receiving catch-up MMR, compared to 0.2% (n = 12) in the cohort signposted to general practice. Over time, the difference in increase between the two cohorts was 1.4%, analysed using the chi-squared comparison of proportions test, providing strong evidence (P < 0.0001) that school nurse delivery of catch-up MMR is effective at increasing coverage. The findings also suggest that school nurse delivery of catch-up MMR may benefit Black, Asian and minority ethnic children and those from more deprived backgrounds.

CONCLUSIONS

It is recommended that commissioners of school-aged immunization services incorporate the delivery of catch-up MMR doses in their contracts with school nurses.

Using Machine Learning to Compare Provaccine and Antivaccine Discourse Among the Public on Social Media: Algorithm Development Study

BACKGROUND

Despite numerous counteracting efforts, antivaccine content linked to delays and refusals to vaccinate has grown persistently on social media, while only a few provaccine campaigns have succeeded in engaging with or persuading the public to accept immunization. Many prior studies have associated the diversity of topics discussed by antivaccine advocates with the public's higher engagement with such content. Nonetheless, a comprehensive comparison of discursive topics in pro- and antivaccine content in the engagement-persuasion spectrum remains unexplored.

OBJECTIVE

We aimed to compare discursive topics chosen by pro- and antivaccine advocates in their attempts to influence the public to accept or reject immunization in the engagement-persuasion spectrum. Our overall objective was pursued through three specific aims as follows: (1) we classified vaccine-related tweets into provaccine, antivaccine, and neutral categories; (2) we extracted and visualized discursive topics from these tweets to explain disparities in engagement between pro- and antivaccine content; and (3) we identified how those topics frame vaccines using Entman's four framing dimensions.

METHODS

We adopted a multimethod approach to analyze discursive topics in the vaccine debate on public social media sites. Our approach combined (1) large-scale balanced data collection from a public social media site (ie, 39,962 tweets from Twitter); (2) the development of a supervised classification algorithm for categorizing tweets into provaccine, antivaccine, and neutral groups; (3) the application of an unsupervised clustering algorithm for identifying prominent topics discussed on both sides; and (4) a multistep qualitative content analysis for identifying the prominent discursive topics and how vaccines are framed in these topics. In so doing, we alleviated methodological challenges that have hindered previous analyses of pro- and antivaccine discursive topics.

RESULTS

Our results indicated that antivaccine topics have greater intertopic distinctiveness (ie, the degree to which discursive topics are distinct from one another) than their provaccine counterparts (t₁₂₂=2.30, P=.02). In addition, while antivaccine advocates use all four message frames known to make narratives persuasive and influential, provaccine advocates have neglected having a clear problem statement.

CONCLUSIONS

Based on our results, we attribute higher engagement among antivaccine advocates to the distinctiveness of the topics they discuss, and we ascribe the influence of the vaccine debate on uptake rates to the comprehensiveness of the message frames. These results show the urgency of developing clear problem statements for provaccine content to counteract the negative impact of antivaccine content on uptake rates.

Social determinants of pertussis and influenza vaccine uptake in pregnancy: a national cohort study in England using electronic health records

OBJECTIVE

To examine the social determinants of influenza and pertussis vaccine uptake among pregnant women in England.

DESIGN

Nationwide population-based cohort study.

SETTING

The study used anonymised primary care data from the Clinical Practice Research Datalink and linked Hospital Episode Statistics secondary care data.

PARTICIPANTS

Pregnant women eligible for pertussis (2012-2015, n=68 090) or influenza (2010/2011-2015/2016, n=152 132) vaccination in England.

MAIN OUTCOME MEASURES

Influenza and pertussis vaccine uptake.

RESULTS

Vaccine uptake was 67.3% for pertussis and 39.1% for influenza. Uptake of both vaccines varied by region, with the lowest uptakes in London and the North East. Lower vaccine uptake was associated with greater deprivation: almost 10% lower in the most deprived quintiles compared with the least deprived for influenza (34.5% vs 44.0%), and almost 20% lower for pertussis (57.7% vs 76.0%). Lower uptake for both vaccines was also associated with non-white ethnicity (lowest among women of black ethnicity), maternal age under 20 years and a greater number of children in the household. The associations between all social factors and vaccine uptake were broadly unchanged in fully adjusted models, suggesting the social determinants of uptake were largely independent of one another. Among 3111 women vaccinated against pertussis in their first eligible pregnancy and pregnant again, 1234 (40%) were not vaccinated in their second eligible pregnancy.

CONCLUSIONS

Targeting promotional campaigns to pregnant women who are younger, of non-white ethnicity, with more children, living in areas of greater deprivation or the London or North East regions, has potential to reduce vaccine-preventable disease among infants and pregnant women, and to reduce health inequalities. Vaccination promotion needs to be sustained across successive pregnancies. Further research is needed into whether the effectiveness of vaccine promotion strategies may vary according to social factors.

Measles, mumps, rubella prevention: how can we do better?

INTRODUCTION

Measles, mumps, and rubella incidence decreased drastically following vaccination programs' implementation. However, measles and mumps' resurgence was recently reported, outbreaks still occur, and challenges remain to control these diseases.

AREAS COVERED

This qualitative narrative review provides an objective appraisal of the literature regarding current challenges in controlling measles, mumps, rubella infections, and interventions to address them.

EXPERT OPINION

While vaccines against measles, mumps, and rubella (including trivalent vaccines) are widely used and effective, challenges to control these diseases are mainly related to insufficient immunization coverage and changing vaccination needs owing to new global environment (e.g. traveling, migration, population density). By understanding disease transmission peculiarities by setting, initiatives are needed to optimize vaccination policies and increase vaccination coverage, which was further negatively impacted by COVID-19 pandemic. Also, awareness of the potential severity of infections and the role of vaccines should increase. Reminder systems, vaccination of disadvantaged, high-risk and difficult-to-reach populations, accessibility of vaccination, healthcare infrastructure, and vaccination services management should improve. Outbreak preparedness should be strengthened, including implementation of high-quality surveillance systems to monitor epidemiology. While the main focus should be on these public health initiatives to increase vaccination coverage, slightly more benefits could come from evolution of current vaccines.

Vaccine acceptability, uptake and completion amongst men who have sex with men: A systematic review, meta-analysis and theoretical framework

BACKGROUND

Due to an increased risk of sexually transmitted infections (STIs), gay, bisexual and other men who have sex with men (MSM) have been recommended to receive vaccinations against human papillomavirus, meningitis C and hepatitis A/B. This review aimed to compare the rates of vaccine acceptability, uptake and completion, and to identify determinants of vaccine outcomes specific to MSM to inform a theoretical framework.

METHODS

In January 2020 four databases were explored to identify vaccination behaviours and associated factors among MSM. A narrative systematic review and meta-analysis were performed. Data were synthesised for theoretical modelling.

RESULTS

Seventy-eight studies, mostly from the USA, were included. The average vaccine acceptability was 63% (median = 72%, range: 30%-97%), vaccine uptake 45% (median = 42%, range: 5%-100%) and vaccine completion 47% (median = 45%, range: 12%-89%). Six categories of factors associated with vaccination acceptability, uptake and completion were conceptualised: Individual (e.g., demographic and psychosocial); Interpersonal (e.g., peer education); Healthcare provider (e.g., vaccine recommendation); Organisational and practice setting (e.g., routine collection of patient sexual orientation information that is integrated into a clinical decision support system); Community environment (e.g., targeted health promotion campaigns); and National, state and local policy environment (e.g., public health guidelines targeting MSM).

CONCLUSION

Despite overall high levels of acceptability, uptake and completion rates were below targets predicted by cost-effectiveness modelling across all recommended vaccines. These parameters may need to be adjusted for more precise estimations of cost-effectiveness. Addressing the multiple levels of determinants, as outlined in our theoretical framework, will help guide interventions to increase vaccine completion among MSM.

Participation in an action research project on vaccine services for children: relationship with vaccine delays

Multicomponent interventions are effective in improving vaccine coverage. However, few studies have assessed their effect on timely vaccination. The aim of this study was to compare the proportion of children with vaccine delays at 2- and 12-month visits according to whether or not health centers have participated in an action research project on the organization of vaccination services for 0-5-year-olds. The action research project included a multicomponent intervention and was conducted between 2011 and 2015 in Quebec, Canada. An ecological before/after design was used for this analysis. A total of 264,579 DTaP-IPV-Hib (2-month visits) and 240,541 Men-C-C (12-month visits) vaccine doses were administered during 2011-2012 to 2014-2015 fiscal years, including 19% in 14 participating health centers and the remaining in 78 nonparticipating centers. Vaccine delays demonstrated a more pronounced decreasing trend in participating versus nonparticipating health centers (p < .0001 at 2 and 12 months). Between 2011-2012 and 2014-2015, participating centers managed to eliminate 35% of their vaccine delays at 2-month visits and 33% at 12-month visits, whereas nonparticipating centers eliminated 19% of delays at both visits. Our results are consistent with a positive impact of the multicomponent intervention, despite the fact that it had not specifically aimed at decreasing vaccine delays.

Practice nurses' perceptions of their immunization role and strategies used to promote measles, mumps, and rubella vaccine uptake in 2014 - 2018: A qualitative study

AIM

The aim of this study was to explore which aspects of their role practice nurses perceive to be most influential and the strategies they employ to promote the MMR vaccine.

DESIGN

Qualitative study employing in depth interviews.

METHOD

Fifteen London based practice nurses, nine in 2014 and six in 2018, took part in semi-structured interviews that were audio recorded and transcribed verbatim. Qualitative content analysis was used to systematically manage, analyse, and identify themes.

RESULTS

Analysis of data identified aspects of their role practice nurses perceived to be most influential (the themes) including: promoting vaccination, assisting parents' to make informed decisions, and provided insight into how they used specific strategies to achieve these in practice. These themes were consistent over both phases of the study.

CONCLUSION

The findings provide an understanding of: (i) the practice nurses perceptions of the most important aspects of their role when promoting the measles, mumps, and rubella vaccine; and (ii) the strategies they implemented in practice to achieve these. The latter included assisting parents in their immunization decisions and was facilitated by practice nurses engaging with parents to provide relevant evidence to address parent queries, dispel misconceptions and tailor strategies to promote the measles, mumps, and rubella vaccine.

IMPACT

This study addresses the paucity of literature available that specifically explores practice nurses' perceptions of their role concerning the measles, mumps, and rubella vaccine. The findings reveal how practice nurses promote the measles, mumps, and rubella vaccine by identifying strategies to enable parents to make informed decisions. At a time of an increasing incidence of measles, practice nurses have an important public health role in achieving herd immunity levels for measles, mumps, and rubella.

The provision of additional services in primary care: a cross-sectional study of incentivised additional services, social deprivation, and ethnic group

Background

Primary care in England is contracted to provide essential services. Many practices also provide additional services, termed ‘directed enhanced services’ (DES), for extra income. The optional nature of DES may result in inequitable service delivery.

Aim

To determine the range of DES activity and equity of service provision.

Design & setting

A cross-sectional analysis of data from general practices in England took place from 2018–2019.

Method

DES were defined in terms of activity level and measured as total DES funding per registered patient. Linear regression modelling was used to explore the relationship between DES activity, practice, and population characteristics.

Results

Data were available for 6873 practices providing up to 10 DES in the initial sample. Due to negative funding amounts and a list size of ≤750 registered patients, 24 practices were excluded. Of the final sample (n = 6849), highest DES provision was for influenza and pneumococcal immunisation (99.9%), pertussis immunisation (97.9%), rotavirus and shingles immunisation (99.9%), meningitis immunisation (99.7%), and childhood immunisation (99.6%); lowest provision was for extended hours access (72.4%), violent patient services (2.0%), and out-of-area urgent care (1.3%). Mean DES funding was £6.25 per patient. In deprived areas, DES funding was £0.35 lower (95% confidence interval [CI] = £0.60 to £0.10) per patient (most versus least deprived quintiles); ethnic group-related differences were not significant. DES funding was higher in practices with more GPs or practice nurses per patient. In deprived communities, there was less immunisation activity (including influenza, pneumococcal, meningitis, childhood, and rotavirus and shingles immunisation) and provision of extended hours access; however, learning disability checks provision was greater in these communities.

Conclusion

DES provision is lower in deprived areas (notably for immunisations and some aspects of access) but higher in better staffed practices. Voluntary quality schemes may contribute to widening health inequalities.

Identifying interventions with Gypsies, Roma and Travellers to promote immunisation uptake: methodological approach and findings

BACKGROUND

In the UK, Gypsy, Roma and Traveller (GRT) communities are generally considered to be at risk of low or variable immunisation uptake. Many strategies to increase uptake for the general population are relevant for GRT communities, however additional approaches may also be required, and importantly one cannot assume that "one size fits all". Robust methods are needed to identify content and methods of delivery that are likely to be acceptable, feasible, effective and cost effective. In this paper, we describe the approach taken to identify potential interventions to increase uptake of immunisations in six GRT communities in four UK cities; and present the list of prioritised interventions that emerged.

METHODS

This work was conducted in three stages: (1) a modified intervention mapping process to identify ideas for potential interventions; (2) a two-step prioritisation activity at workshops with 51 GRTs and 25 Service Providers to agree a prioritised list of potentially feasible and acceptable interventions for each community; (3) cross-community synthesis to produce a final list of interventions. The theoretical framework underpinning the study was the Social Ecological Model.

RESULTS

Five priority interventions were agreed across communities and Service Providers to improve the uptake of immunisation amongst GRTs who are housed or settled on an authorised site. These interventions are all at the Institutional (e.g. cultural competence training) and Policy (e.g. protected funding) levels of the Social Ecological Model.

CONCLUSIONS

The "upstream" nature of the five interventions reinforces the key role of GP practices, frontline workers and wider NHS systems on improving immunisation uptake. All five interventions have potentially broader applicability than GRTs. We believe that their impact would be enhanced if delivered as a combined package. The robust intervention development and co-production methods described could usefully be applied to other communities where poor uptake of immunisation is a concern.

STUDY REGISTRATION

Current Controlled Trials ISRCTN20019630, Date of registration 01-08-2013, Prospectively registered.

Using the Tailoring Immunization Programmes guide to improve child immunisation in Umina, New South Wales: we could still do better

In the Central Coast Local Health District of New South Wales, Australia, childhood immunisation (CI) rates are around 95%, but pockets of underimmunisation exist. Using the World Health Organization's Tailoring Immunization Programmes, we identified areas of potential low vaccine coverage using Australian Immunisation Register (AIR) data (2016-18) and investigated factors that influence CI. Individual and group interviews with carers, community members and service providers (n=52 participants) were conducted. Data were analysed thematically and the themes presented to stakeholders for feedback before finalisation. During 2018, Umina had 218 children at least 1 month overdue for at least one vaccination. Five themes emerged: (1) broader socioeconomic factors may apply pressures that influence CI; (2) parents largely supported immunisation and knew of its benefits to their children and the community; (3) immunisation service providers are committed, experienced and collaborate with community partners; (4) there is potential to increase access to free immunisation services in Umina; and (5) AIR data and reminder systems could be better used to inform service delivery and prompt parents before immunisations are due. This study identified opportunities to improve CI coverage in Umina and new information useful in developing a tailored immunisation strategy. Awareness of the pressures socioeconomic factors may have on families could help plan and deliver supportive primary health care that includes equitable access to immunisation.

Interventions delivered in secondary or tertiary medical care settings to improve routine vaccination uptake in children and young people: a scoping review protocol

OBJECTIVE

The objective of this review is to identify and collate the available evidence, and to produce an overview of interventions delivered in secondary and tertiary healthcare settings with the aim of improving vaccination uptake in children and young people.

INTRODUCTION

Vaccine hesitancy appears in the World Health Organization's Ten Threats to Global Health in 2019. Time spent in secondary or tertiary healthcare settings with a child or young person may present an opportunity to deliver vaccination-focused interventions. National Institute for Health and Care Excellence guidance highlights a gap in the evidence of the effectiveness of different interventions aimed at increasing immunization uptake among children and young people.

INCLUSION CRITERIA

Quantitative studies that describe interventions delivered in secondary and tertiary care settings will be included. Participants will include children and young people aged less than 16 years and/or their parents/carers (potentially interventions could be delivered to the child-parent/carer dyad) present in a secondary or tertiary care setting as either a patient or relative.

METHODS

This scoping review will be conducted using MEDLINE, CINAHL, Cochrane Library, Embase, Web of Science, as well as gray literature. The scoping review will exclude publications not available in English and any publication older than 30 years. Two reviewers will independently select articles using the inclusion criteria, based on their title and abstract. Data will be extracted from selected full text articles using a data extraction tool based on JBI recommendations. Study findings will be presented in tabular form detailing the interventions identified in the literature.

Towards equity in immunisation

In the World Health Organization (WHO) European Region, differences in uptake rates of routine childhood immunisation persist within and among countries, with rates even falling in some areas. There has been a tendency among national programmes, policymakers and the media in recent years to attribute missed vaccinations to faltering demand or refusal among parents. However, evidence shows that the reasons for suboptimal coverage are multifactorial and include the social determinants of health. At the midpoint in the implementation of the European Vaccine Action Plan 2015–2020 (EVAP), national immunisation programmes should be aware that inequity may be a factor affecting their progress towards the EVAP immunisation targets. Social determinants of health, such as individual and household income and education, impact immunisation uptake as well as general health outcomes – even in high-income countries. One way to ensure optimal coverage is to make inequities in immunisation uptake visible by disaggregating immunisation coverage data and linking them with already available data sources of social determinants. This can serve as a starting point to identify and eliminate underlying structural causes of suboptimal uptake. The WHO Regional Office for Europe encourages countries to make the equitable delivery of vaccination a priority.

Revue de la littérature sur les interventions en milieu scolaire concernant la vaccination anti-HPV

INTRODUCTION

Human papillomavirus infection is the most common sexually transmitted infection and is associated with cervical cancer and several other cancers. Although the human papillomavirus vaccine is highly effective and has an excellent safety record, vaccination coverage rates vary around the world and are very low in France.Purpose of research: A literature review on the last five years in the MEDLINE and Public Health Databases was conducted in November 2017. Sixteen studies on school-based interventions for human papillomavirus vaccination in girls aged 11 to 19&#160;years were selected and analyzed.

RESULTS

Half of the studies concerned underage girls in middle and high schools or their parents and the other half major students. Education through written information, presentation or discussion increased knowledge about human papillomavirus infection and vaccine prevention, even in the medium term. The interventions that had the greatest impact were those that used personalization of the message, combining information or sources and implementing pre-intervention questionnaires. Knowledge was not always correlated with effective vaccination.

CONCLUSIONS

Educational interventions increase knowledge about human papillomavirus and vaccination intention but not vaccination. Further studies seem necessary to understand the gap between the level of knowledge and its impact on immunization coverage.

Inequality in measles vaccination coverage in the "big six" countries of the WHO South-East Asia region

The "big six" countries (Bangladesh, India, Indonesia, Myanmar, Nepal, and Thailand) in the World Health Organization South-East Asia Region (WHO SEAR) are currently facing severe challenges in measles elimination and consequent childhood mortality reduction, with inadequacies and inequalities in the coverage of the measles-containing-vaccine first-dose (MCV1) being major obstacles. However, these issues of inequality in MCV1 coverage have not yet been systematically examined. We used data from the latest Demographic and Health Surveys and Multiple Indicator Cluster Surveys. To provide a comprehensive picture of existing MCV1 coverage gaps, data were disaggregated by geographic location, as well as by socioeconomic and nutritional dimensions. National MCV1 coverage ranged from 77% in Myanmar to 92% in Thailand. Only nine of the 104 sub-national districts had achieved the 95% MCV1 coverage goal as set by the WHO. Geographic inequalities were more pronounced in countries with lower coverage levels. Areas in clusters with poor MCV1 coverage performances as well as disadvantaged socioeconomic profiles require increased attention. Inequalities were evident in all countries, except Thailand, and were more pronounced in the sectors of wealth, education, antenatal care (ANC) status, and vitamin A supplementation (VAS) when compared against the areas of gender and urban/rural residence. Wealth-related inequality in Bangladesh, education-related inequality in Indonesia, ANC-related inequalities in Myanmar and Nepal, and VAS-related inequalities in Indonesia and Myanmar were all noteworthy. Equity-oriented changes in policies focusing on health promotion and integrated interventions among disadvantaged populations need to be implemented in order to increase MCV1 coverage and reduce childhood mortality.

Understanding vaccine acceptance and demand-and ways to increase them

Vaccination saves millions of lives, and the World Health Organization (WHO) European Region celebrated record high coverage in 2018. Still, national or sub-national coverage is insufficient to stop the spread of vaccine-preventable diseases. Health authorities are increasingly aware of the need to prioritize the “demand” side of vaccination. Achieving high and equitable vaccination uptake in all population groups is not a quick-fix; it requires long-term investment in multifaceted interventions, informed by research with the target groups. The WHO focuses on both individual and context determinants of vaccination behaviours. Individual determinants include risk perceptions, (dis)trust and perceived constraints; insights from psychology help us understand these. Context determinants include social norms, socioeconomic status and education level, and the way health systems are designed, operate and are financed. The WHO recommends using a proven theoretical model to understand vaccination behaviours and has adapted the “COM‑B model” for their Tailoring Immunization Programmes (TIP) approach. This adapted model is described in the article. Informed by insights into the factors affecting vaccination behaviours, interventions and policies can be planned to increase vaccination uptake. Some evidence exists on proven methods to do this. At the individual level, some interventions have been seen to increase vaccination uptake, and experimental studies have assessed how certain messages or actions affect vaccination perceptions. At the context level, there is more documentation for effective strategies, including those that focus on making vaccination the easy, convenient and default behaviour and that focus on the interaction between caregivers and health workers.

Mobile outreach health services for mothers and children in conflict-affected and remote areas: a population-based study from Afghanistan

OBJECTIVE

To assess whether sustained, scheduled mobile health team (MHT) services increase antenatal care (ANC), postnatal care (PNC) and childhood immunisation in conflict-affected and remote regions of Afghanistan.

DESIGN

Cross-sectional, population-based study from 2013 to 2017. Proportions were compared using multivariable linear regression adjusted for clustering and socio-demographic variables.

SETTING

54 intervention and 56 control districts in eight Afghanistan provinces.

PARTICIPANTS

338 796 pregnant women and 1 693 872 children aged under 5 years.

INTERVENTIONS

'Intervention districts' that received MHT services for 3 years compared with 'control districts' in the same province without any MHT services over the same period.

MAIN OUTCOME MEASURES

District-level and clinic-level ANC, PNC, childhood immunisation (pentavalent 3, measles 1), integrated management of childhood immunisation services.

RESULTS

Proportion of pregnant women receiving at least one ANC visit was higher in intervention districts (83.6%, 161 750/193 482) than control districts (61.3%, 89 077/145 314) (adjusted mean difference (AMD) 14.8%;95% CI: 1.6% to 28.0%). Proportion of children under 1 year receiving their first dose of measles vaccine was higher in intervention (73.8%, 142 738/193 412) than control districts (57.3%, 83 253/145 293) (AMD 12.8;95% CI: 2.1% to 23.5%). There was no association with PNC (AMD 2.8%;95% CI: -5.1% to 10.7%). MHTs did not increase clinic-level service provision for ANC (AMD 41.32;95% CI: -52.46 to 135.11) or any other outcomes.

CONCLUSIONS

Sustained, scheduled MHT services to conflict-affected and remote regions were associated with improved coverage of important maternal and child health interventions. Outreach is an essential service and not just an 'optional extra' for the most deprived mothers and children.

[Result of a strategy using reminders before and after date of vaccination to improve timeliness of vaccination at six month]

The impact of immunization depends on timely application of the vaccines, especially relevant in children. Successful strategies for improving timeliness include the use of nominalized records and follow-up mechanisms. This study assessed the result of reminders before and after the scheduled date of vaccination to improve timely vaccination at six months. A before-and-after intervention study was performed with a time series and comparator group with 1,856 children from Villa María, Córdoba, Argentina. The strategy was implemented in the city's public services and consisted of preparing weekly vaccination schedules, performing follow-up, and contacting and/or making active searches for no-show cases. Assessment of the result used the percentage of timely vaccination with the third dose of the pentavalent vaccine. Time series were built for each group, before and after, and were analyzed with a simple linear model. Means of the percentages were calculated with their confidence intervals, using bootstrap, and compared with the permutation method. In the intervention group, the mean percentage of timely vaccination increased significantly by 2.6 times, reaching 61.7% (56.2; 78.1). No significant increase occurred in the comparator group: p = 0.1101. The mean rates were similar before the implementation. Timely vaccination improved in children receiving the intervention. The results indicate that the proposed strategy to use nominalized records can reduce the delay in application of vaccines.

Coverage, quality, and correlates of childhood immunization in slums under national immunization program of India: A cross-sectional study

Adequate and quality immunization coverage plays a key role in controlling the outbreaks of vaccine preventable diseases. Places where immunization coverage is low, vaccine preventable diseases contribute to worse health outcomes. This is especially true in Indian slum dwellings where 33.0% of the urban population live. The aim of the study was to explore the coverage, quality, and correlates of primary immunization under national immunization program among children aged 12–23 months, living in slums of Mumbai. A community based cross-sectional survey was conducted. Parents or caretakers of 550 eligible children aged 12–23 months were interviewed using a structured interview schedule. Regression analysis was used to detect correlates of full immunization coverage (children who received one dose each of BCG, measles, and three doses each of DPT, OPV, and HBV by his/her first birthday) and of quality immunization coverage (children who received primary vaccines at appropriate age and intervals as mentioned above and had filled immunization card). Out of total 550 children, 402 (73.1%), 131 (23.8%), and 17 (3.1%) were fully, partially, and unimmunized, respectively. Almost 86.0% children received quality immunization coverage. In the regression analysis, reminder for immunization services was found to be the single most significant correlate of full and quality immunization coverage.

In this study, full immunization coverage was found to be below the expected level. This study also revealed that the awareness regarding the importance of adequate immunization was still lacking in the slum population. Emphasizing on reminders for immunization services, encouraging institutional deliveries, and scaling up use of postnatal care services may act as keys to improving the immunization coverage in Indian slums.

Communication around HPV vaccination for adolescents in low- and middle-income countries: a systematic scoping overview of systematic reviews

BACKGROUND

Human papillomavirus (HPV) infection causes cervical cancer. More than 80% of those diagnosed with cervical cancer live in low- and middle-income countries (LMICs). The World Health Organization recommends vaccination as a public health measure against cervical cancer. Communication interventions are able to change how people think about vaccination and are thus instrumental in addressing vaccine hesitancy. Our aim was to provide a broad scoping overview of the available evidence on communication with adolescents, parents, and other stakeholders around HPV vaccination for adolescents, with a specific focus on LMICs.

METHODS

We conducted a systematic scoping overview of systematic reviews addressing a range of questions regarding communication around HPV vaccination. We considered reviews published between 2007 and 2018 focusing on communication around HPV vaccination and that searched for qualitative or quantitative studies for inclusion. We searched the Epistemonikos database which includes reviews from multiple electronic databases. Two overview authors screened titles and abstracts and examined potentially eligible reviews in full text. Data extraction was performed by one overview author and verified by a second. We assessed the reliability of the included reviews using an adapted version of AMSTAR 2.

RESULTS

We included twelve reviews in our overview. Four reviews assessed the effectiveness of communication interventions. These interventions intended to inform or educate about HPV and HPV vaccination, such as videos and fact sheets, or to remind or recall, such as text message reminders. Eight reviews assessed factors associated with HPV vaccination uptake, including communication-related factors such as whether the vaccine was recommended by a physician and people's knowledge regarding the vaccine. Nine reviews searched for studies from LMICs, but most found only a small number of studies from these countries.

CONCLUSIONS

The small number of studies identified from LMICs is of concern as these countries face the largest burden of disease related to HPV. This scoping overview also found and excluded a number of reviews because of important methodological limitations, highlighting the need for future reviews to use appropriate methods. The overview indicates areas in which further primary studies are needed on HPV vaccination communication in LMICs.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework https://osf.io/agzb4/.

Social inequities in vaccination coverage among infants and pre-school children in Europe and Australia - a systematic review

BACKGROUND

Herd immunity levels of vaccine uptake are still not reached in some high-income countries, usually in countries with persisting social inequities in uptake. Previous studies have focused on factors within one health care system. This study takes a broader health care systems approach by reviewing the socioeconomic distribution of vaccination coverage on the national level in light of structural and organizational differences of primary care for children.

METHODS

A systematic literature review of socio-economic patterns of uptake of Measles-Mumps-Rubella (MMR) and/or Diphteria-Tetanus-Pertusis (DTP) in population based studies of children 0-5 years of age living in the 30 European Economic Area (EEA) or European Free Trade Association (EFTA) countries and Australia, was carried out using the PRISMA guidelines. The health care system in the countries in the study were categorized by degree of freedom of the primary care provider (hierarchical or non-hierarchical) and whether preventive services were provided in a separate organization (well-baby clinics).

RESULTS

The review identified 15 studies from 10 European countries and Australia that fulfilled the criteria. Although the heterogeneity of the socio-economic indicators did not allow for a conclusive meta-analysis, the study pointed towards lower levels of inequities in primary care models with well-baby clinics. In non-hierarchical primary care organizations that also lacked well-baby clinics, socioeconomic gaps in uptake were often found to be large.

CONCLUSION

This review indicates that structural and organizational aspects of health care systems for young children are important for equity in vaccine uptake.

Barriers and enablers to adolescent self-consent for vaccination: A mixed-methods evidence synthesis

•

Synthesis of studies related to self-consent procedures for adolescent vaccination.

•

Robust systematic review methodology used to identify and appraise the literature.

•

There is a need to clarify policy and address professionals’ misunderstandings.

•

Concerns about professional practice and relationships with parents create barriers.

•

Enabling adolescent self-consent entails disputing the primacy of parental consent.

Introduction

The recent global expansion of routine adolescent vaccination programmes has the potential to protect young people against infectious diseases and improve their health. Although the legal framework in many countries permits young people to consent for vaccinations if competent, lack of written parental consent can still prevent uptake. We aimed to review systematically the associated barriers and enablers to implementation of adolescent self-consent procedures.

Methods

A comprehensive search strategy of ten databases from inception to June 2018 was undertaken to identify relevant qualitative and quantitative studies. Titles, abstracts and full texts were assessed for eligibility, and the methodological quality of eligible primary studies evaluated. Thematic synthesis methods were used to interpret and combine qualitative data, and to identify overarching themes as well as similarities and differences within themes. Quantitative data were summarised and, because the data were sufficiently similar in focus, were integrated within the qualitative framework.

Results

Twenty-five publications related to 23 studies were included. Three themes were identified which related to the policy framework, protection, and self-determination. Despite supportive national policy frameworks, implementation of adolescent self-consent procedures can be prevented by local policies, professionals’ misunderstandings of the legal framework and the context in which the vaccination programme is delivered. Motivation to protect young people’s health increased acceptability of adolescent self-consent, but implementation might be prevented to protect the reputation of professionals or relationships with parents. Further, maintaining the role of parents as decision-makers for their child’s healthcare was frequently prioritised over enabling young people’s autonomy to consent.

Conclusions

Barriers to the implementation of adolescent self-consent procedures have implications for young people’s health and uptake of vaccination programmes. There is a need to clarify the policy framework and challenge the primacy of parental consent.

Systematic review registration

PROSPERO CRD42017084509.

Vaccination in England: a review of why business as usual is not enough to maintain coverage

BACKGROUND

The vaccine system in England underwent radical changes in 2013 following the implementation of the Health and Social Care Act. There have since been multi-year decreases in coverage of many vaccines. Healthcare professionals have reported finding the new system fragmented and challenging. This study aims to produce a logic model of the new system and evaluate the available evidence for interventions to improve coverage.

METHODS

We undertook qualitative document analysis to develop the logic model using process evaluation methods. We performed a systematic review by searching 12 databases with a broad search strategy to identify interventions studied in England conducted between 2006 and 2016 and evaluated their effectiveness. We then compared the evidence base to the logic model.

RESULTS

We analysed 83 documents and developed a logic model describing the core inputs, processes, activities, outputs, outcomes and impacts of the new vaccination system alongside the programmatic assumptions for each stage. Of 9,615 unique articles, we screened 624 abstracts, 45 full-text articles, and included 16 studies: 8 randomised controlled trials and 8 quasi-experimental studies. Four studies suggest that modifications to the contracting and incentive systems can increase coverage, but changes to other programme inputs (e.g. human or capital resources) were not evaluated. Four multi-component intervention studies modified activities and outputs from within a GP practice to increase coverage, but were part of campaigns or projects. Thus, many potentially modifiable factors relating to routine programme implementation remain unexplored. Reminder/recall systems are under-studied in England; incentive payments to adolescents may be effective; and only two studies evaluated carer information.

CONCLUSIONS

The evidence base for interventions to increase immunisation coverage in the new system in England are limited by a small number of studies and by significant risk of bias. Several areas important to primary care remain unexplored as targets for interventions, especially modification to organisational management.

The Future of Precision Medicine: Potential Impacts for Health Technology Assessment

OBJECTIVE

Precision medicine allows healthcare interventions to be tailored to groups of patients based on their disease susceptibility, diagnostic or prognostic information, or treatment response. We analysed what developments are expected in precision medicine over the next decade and considered the implications for health technology assessment (HTA) agencies.

METHODS

We performed a pragmatic literature search to account for the large size and wide scope of the precision medicine literature. We refined and enriched these results with a series of expert interviews up to 1 h in length, including representatives from HTA agencies, research councils and researchers designed to cover a wide spectrum of precision medicine applications and research.

RESULTS

We identified 31 relevant papers and interviewed 13 experts. We found that three types of precision medicine are expected to emerge in clinical practice: complex algorithms, digital health applications and 'omics'-based tests. These are expected to impact upon each stage of the HTA process, from scoping and modelling through to decision-making and review. The complex and uncertain treatment pathways associated with patient stratification and fast-paced technological innovation are central to these effects.

DISCUSSION

Innovation in precision medicine promises substantial benefits but will change the way in which some health services are delivered and evaluated. The shelf life of guidance may decrease, structural uncertainty may increase and new equity considerations will emerge. As biomarker discovery accelerates and artificial intelligence-based technologies emerge, refinements to the methods and processes of evidence assessments will help to adapt and maintain the objective of investing in healthcare that is value for money.

A process evaluation of how the routine vaccination programme is implemented at GP practices in England

BACKGROUND

In recent years, the incidence of several pathogens of public health importance (measles, mumps, pertussis and rubella) has increased in Europe, leading to outbreaks. This has included England, where GP practices implement the vaccination programme based on government guidance. However, there has been no study of how implementation takes place, which makes it difficult to identify organisational variation and thus limits the ability to recommend interventions to improve coverage. The aim of this study is to undertake a comparative process evaluation of the implementation of the routine vaccination programme at GP practices in England.

METHODS

We recruited a sample of geographically and demographically diverse GP practices through a national research network and collected quantitative and qualitative data as part of a Time-Driven Activity-Based Costing analysis between May 2017 and February 2018. We conducted semi-structured interviews with practice staff involved in vaccination, who then completed an activity log for 2 weeks. Interviews were transcribed and coded using a framework method.

RESULTS

Nine practices completed data collection from diverse geographic and socio-economic contexts, and 52 clinical and non-clinical staff participated in 26 interviews. Information relating to 372 vaccination appointments (233 childhood and 139 adult appointments) was captured using activity logs. We have defined a 14-stage care delivery value chain and detailed process map for vaccination. Areas of greatest variation include the method of reminder and recall activities, structure of vaccination appointments and task allocation between staff groups. For childhood vaccination, mean appointment length was 15.9 min (range 9.0-22.0 min) and 10.9 min for adults (range 6.8-14.1 min). Non-clinical administrative activities comprised 59.7% total activity (range 48.4-67.0%). Appointment length and total time were not related to coverage, whereas capacity in terms of appointments per eligible patient may improve coverage. Administrative tasks had lower fidelity of implementation.

CONCLUSIONS

There is variation in how GP practices in England implement the delivery of the routine vaccination programme. Further work is required to evaluate capacity factors in a wider range of practices, alongside other contextual factors, including the working culture within practices.

The effects of public health policies on health inequalities in high-income countries: an umbrella review

BACKGROUND

Socio-economic inequalities are associated with unequal exposure to social, economic and environmental risk factors, which in turn contribute to health inequalities. Understanding the impact of specific public health policy interventions will help to establish causality in terms of the effects on health inequalities.

METHODS

Systematic review methodology was used to identify systematic reviews from high-income countries that describe the health equity effects of upstream public health interventions. Twenty databases were searched from their start date until May 2017. The quality of the included articles was determined using the Assessment of Multiple Systematic Reviews tool (AMSTAR).

RESULTS

Twenty-nine systematic reviews were identified reporting 150 unique relevant primary studies. The reviews summarised evidence of all types of primary and secondary prevention policies (fiscal, regulation, education, preventative treatment and screening) across seven public health domains (tobacco, alcohol, food and nutrition, reproductive health services, the control of infectious diseases, the environment and workplace regulations). There were no systematic reviews of interventions targeting mental health. Results were mixed across the public health domains; some policy interventions were shown to reduce health inequalities (e.g. food subsidy programmes, immunisations), others have no effect and some interventions appear to increase inequalities (e.g. 20 mph and low emission zones). The quality of the included reviews (and their primary studies) were generally poor and clear gaps in the evidence base have been highlighted.

CONCLUSIONS

The review does tentatively suggest interventions that policy makers might use to reduce health inequalities, although whether the programmes are transferable between high-income countries remains unclear.

TRIAL REGISTRATION

PROSPERO registration number: CRD42016025283.

Sociodemographic predictors are associated with compliance to a vaccination-reminder in 9692 girls age 14, Denmark 2014-2015

We aimed to identify sociodemographic predictors of compliance after receiving a personalised reminder on lacking vaccinations against MMR (Measles, Mumps, Rubella) and/or HPV (Human Papilloma Virus) among parents of Danish adolescent girls. A nationwide register-based study, including all 14-year-old girls (15 May 2014-14 May 2015) lacking either MMR, HPV-vaccination or both. Vaccination-compliance following a postal reminder was modelled using multivariable logistic regression and included the following socio-demographic predictors: maternal age, education, employment and ethnicity. Birth order, number of siblings, family-structure, location of residence, and household income. The parents of 9692 girls received a reminder. Out of 4940 exclusively lacking an HPV-vaccine, 15.3% were subsequently vaccinated. Among 2026 only lacking an MMR vaccination, 8.5% were vaccinated. Among 2726 girls lacking both, 5% received an HPV, 4.4% an MMR and 5.4% received both vaccinations. We identified sociodemographic differences between reminderletter-compliers and non-compliers, also according to vaccination types. Non-western descendants were more likely to receive HPV-vaccination, although the association was only significant for those who only lacked HPV (OR 2.02, 95% 1.57-2.59). For girls only lacking an MMR, regional differences were identified. Among girls lacking both vaccines, girls of mothers with intermediate (OR 0.63, 0.42-0.95) or basic education (OR 0.43, 0.24-0.75) were less likely to be vaccinated compared to girls of higher educated mothers. Reminders were in particular effective in increasing HPV uptake among immigrants of non-Western ethnicity. We found reminders to be less effective among less educated mothers whose daughters lacked both vaccines. To increase the coverage in this group, additional interventions are needed.

Simple and Elaborated Clinician Reminder Prompts for Human Papillomavirus Vaccination: A Randomized Clinical Trial

OBJECTIVE

To evaluate the effects of simple and elaborated health care provider (HCP) reminder prompts on human papillomavirus (HPV) vaccine initiation rates.

METHODS

Twenty-nine pediatric HCPs serving 5 pediatric clinics were randomized to 1 of 3 arms: 1) usual practice control, 2) simple reminder prompt, and 3) elaborated reminder prompt, which included suggested language for recommending the early adolescent platform vaccines. Prompts were delivered via a computer-based clinical decision support system deployed in the 5 clinics. Eligible patients were ages 11 to 13 years, had not received HPV vaccine, and were due for meningococcal ACWY (MenACWY) vaccine and/or the tetanus, diphtheria, and pertussis booster (Tdap). Receipt of HPV vaccine was determined via automated queries sent to the Indiana immunization registry. Data were analyzed via logistic regression models, with generalized estimating equations used to account for the clustering of patients within HCPs.

RESULTS

Ten HCPs in the control group saw 301 patients, 8 HCPs in the simple prompt group saw 124, and 11 HCPs in the elaborated prompt group saw 223. The elaborated prompt arm had a higher rate of HPV vaccination (62%) than the control arm (45%): adjusted odds ratio, 2.76; 95% confidence interval, 1.07 to 7.14. The simple prompt arm did not differ significantly from the control arm with respect to HPV vaccine initiation, which might have been because of the small sample size for this arm. MenACWY and Tdap rates did not vary across the 3 arms.

CONCLUSIONS

Results suggest that an elaborated HCP-targeted reminder prompt, with suggested recommendation language, might improve rates of HPV vaccine initiation.