Misperceptions about influenza vaccination among parents of healthy young children

Factors Associated With Repeat Pediatric Influenza Vaccination Among Inconsistent Vaccinators

Promoting consistent vaccination practices may help improve suboptimal influenza vaccination rates. This study evaluated the prevalence and correlates of repeat influenza (flu) vaccination among children who had previously received the vaccine inconsistently. An online survey study was conducted in 2022 among parents of commercially insured children ages 3 to 19 years who were previously inconsistently vaccinated. Of 317 respondents, 85% reported that their child received a flu vaccine in the 2021 to 2022 flu season. Among these parents, 61% reported concern that their child would get sick from flu as the most important reason for vaccinating. Repeat vaccination was less likely among parents who reported that school/daycare requirements were a reason for vaccinating in the prior season (odd ratio [OR] = 0.17, 95% confidence interval [CI] = 0.05-0.55). Our findings suggest that school policies may improve vaccination rates among inconsistent vaccinators.

Parental Hesitancy toward Seasonal Influenza Vaccination for Children under the Age of 18 Years and Its Determinants in the Post-Pandemic Era: A Cross-Sectional Survey among 1175 Parents in China

Children's susceptibility to influenza increased after COVID-19 control measures were lifted. This study investigated parental hesitancy toward seasonal influenza vaccination (SIV) for children and its determinants in the post-pandemic era. An online survey of full-time adult factory workers was conducted in Shenzhen, China in December 2023. This analysis was based on 1175 parents who had at least one child under the age of 18 years. Among all parents, 37.1% were hesitant to have their index child receive SIV. Mothers exhibited lower parental hesitancy toward SIV compared to fathers (31.9% versus 41.3%, p < 0.001). After adjusting for significant background characteristics, mothers and fathers who were more satisfied with the SIV health promotion materials, perceived more severe consequences of seasonal influenza for their children, and perceived more benefits, cues to action, and self-efficacy related to their children's SIV were less likely to exhibit hesitancy toward SIV. Higher frequency of exposure to information about the increasing number of patients or severe cases due to seasonal influenza and other upper respiratory infections on social media was associated with lower parental hesitancy toward SIV among fathers but not mothers. There is a strong need to address parental hesitancy toward SIV for children in the post-pandemic era.

Parental Acceptance, Parental Hesitancy, and Uptake of Seasonal Influenza Vaccination among Children Aged 6-59 Months: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis summarises the literature on parental acceptance, parental hesitancy, uptake, and the associated factors of seasonal influenza vaccination (SIV) among children aged 6-59 months. Studies were sourced from the following platforms: PubMed, Web of Science, MEDLINE, and EMBASE databases. A random-effects model was used to evaluate the prevalence and 95% confidence intervals (CI) of parental acceptance, parental hesitancy, and SIV uptake in the last flu season and lifetime among children. A total of 36 studies were included for analysis. The overall prevalence was 64% for parental acceptance (95% CI: 51-75%), 34% for parental hesitancy (95% CI: 22-48%), 41% for SIV uptake in the last flu season (95% CI: 33-50%), and 46% for SIV uptake in a lifetime (95% CI: 20-74%). Associated factors of parental acceptance/hesitancy and uptake included the age of the children or parents, parental education level, household income level, ethnicity, and other modifiable factors, including perceived benefits, perceived barriers, perceived severity, perceived susceptibility, and cues to action related to SIV. Meta-regression analyses revealed regional differences in parental acceptance (Americas: 79% vs. Asia: 60%). The results provided implications informing us of the development of intervention programs targeting parents to improve SIV coverage among young children.

The issue of vaccine refusal: the study of a risky behavior

Purpose

Influenza is the most common seasonal infectious disease that causes permanent social, economic, and medical problems worldwide. Therefore, the most effective way to prevent influenza is through vaccines. The aim of this study is to identify the influence of factors that determine the refusal of influenza vaccine among three subjects groups.

Materials and Methods

A survey was conducted amongst the three high-risk groups in 2018-2019 (Moscow, Russia). The survey involved 1,620 parents and pregnant women (group 1), 324 doctors (group 2), and 433 students (group 3). Poor vaccine uptake was observed among respondents in all three groups.

Results

According to the survey results, only 22.2% of children and 13.8% of adults were vaccinated against influenza. Group 2 showed increased rates with 36.7% of vaccinated adults and 58.7% of children. The lowest adherence to annual vaccinations was recorded in group 3 (only 17.3%). There is also a negative correlation between adherence to vaccination and smoking (-0.66), unhealthy diet (-0.73), poor oral hygiene (-0.61), and insufficient awareness of the need for influenza vaccine as well (-0.81).

Conclusion

Thus, a general lack of vaccination awareness has a fundamental role in forming a negative attitude toward influenza vaccine. It is necessary to conduct research to promote vaccination against influenza to improve vaccine uptake among high-risk groups, particularly students.

Knowledge, Attitudes, and Practices of Influenza Vaccination among Parents of Children with Asthma: A Cross-Sectional Study

Asthma is the most common chronic disease in childhood. Exacerbation is a significant problem for asthmatic patients, and viral infections remain the most frequent triggers of asthma exacerbations. This study explored knowledge, attitudes, and practices (KAP) of parents of asthmatic children towards providing influenza vaccine to their children. This cross-sectional study enrolled parents of asthmatic children who visited the outpatient respiratory clinics of two Jordanian hospitals. The present study enrolled 667 parents of asthmatic children (62.8% female). The median age of the participants' children was 7 years. The results showed that 60.4% of the children with asthma never received a flu vaccine. Most of those who had received the flu vaccine reported that the side effects were mild (62.7%). Asthma duration was positively and significantly associated with increased vaccine hesitancy/rejection (OR = 1.093, 95% CI = (1.004-1.190), p = 0.04; and OR = 1.092, 95% CI = (1.002-1.189), p = 0.044, respectively). As the attitude towards flu vaccine score increases, odds of vaccination hesitancy/rejection decreased (OR = 0.735, 95% CI = (0.676-0.800), p < 0.001; and OR = 0.571, 95% CI = (0.514-0.634), p < 0.001, respectively). The main reasons for vaccination hesitancy/refusal included "I don't think my child needs it" (22.3%) followed by "I forget it" (19.5%). The rate of vaccination among children was low and emphasized the necessity of encouraging parents with asthmatic children to vaccinate their children by conducting health awareness campaigns and also emphasized the role of doctors and other healthcare professionals.

Exploring Critical Factors Associated with Completion of Childhood Immunisation in the Eastern Province of Saudi Arabia

(1) Background: surveillance data from the Saudi Ministry of Health shows that the Kingdom’s large-scale immunisation programme has significantly reduced the mortality and morbidity of the target diseases among children. In this study, we review relevant literature and test a number of hypotheses related to the association between demographic, socio-economic, clinic-related, and parents-related variables and completion of childhood immunisation. In doing so, this study identifies critical factors associated with completion of childhood immunisation and presents important implications to healthcare practitioners, particularly in Saudi Arabia; (2) Literature review: a systematic literature review was conducted to understand what is currently published concerning parents’ immunisation compliance in Saudi Arabia and the factors associated with immunisation compliance. (3) Methods: from March to May 2022, an online survey was administered to parents attending one of the 27 primary health care (PHC) centres in Qatif. Data from parents (n = 353) were analysed using exploratory factor analysis, correlation, and a series of OLS and logistic regression models; (4) Results: parental (child) age was negatively (positively) associated with the completion status of childhood immunisation (both p < 0.05). Parents with positive attitudes, social norms, perceptions towards immunisation, and those working in private companies were more likely to immunise their children (all p < 0.05). Conversely, living in an apartment building, walking to PHCs, waiting longer at PHCs, and having higher knowledge of immunisation were negatively associated with the completion of childhood immunisation (all p < 0.05); (5) Conclusions: several factors that positively or negatively influence the completion of childhood immunisation have been identified. Future studies may investigate the causal link between these factors and parental decision-making regarding childhood immunisation.

An (un)healthy social dilemma: a normative messaging field experiment with flu vaccinations

BACKGROUND

Influenza seasons can be unpredictable and have the potential to rapidly affect populations, especially in crowded areas. Prior research suggests that normative messaging can be used to increase voluntary provision of public goods, such as the influenza vaccine. We extend the literature by examining the influence of normative messaging on the decision to get vaccinated against influenza.

METHODS

We conduct a field experiment in conjunction with University Health Services, targeting undergraduate students living on campus. We use four posters, randomized by living area clusters to advertise flu vaccination clinics during the Fall. The wording on the posters is varied to emphasize the individual benefits of the vaccine, the social benefits of the vaccine or both benefits together. We collect survey data for those vaccinated at the vaccination clinics, and for those not vaccinated via an online survey.

RESULTS

We find that any normative message increases the percentage of students getting the flu vaccine compared with no message. In terms of the likelihood of getting the flu vaccine, emphasizing both the individual and social benefits of vaccination has the largest increase in the vaccination rate (19-20 percentage point increase). However, flu vaccinations did not reach the herd immunity threshold (70% of students vaccinated).

CONCLUSIONS

This study provides evidence that there is a pro-social component that is relevant in individual vaccination decisions which should be accounted for when designing vaccination campaigns. The results of this normative, pro-social messaging experiment could be extended to other at-risk communities where the number of background risks is much larger. This is especially relevant nowadays, as other seasonal vaccines are being rolled out and younger adults are the ones with the lowest uptake.

Lau K, Miraldo M, Hauck K. Bandwagoning, free-riding and heterogeneity in influenza vaccine decisions: An online experiment

'Nudge'-based social norms messages conveying high population influenza vaccination coverage levels can encourage vaccination due to bandwagoning effects but also discourage vaccination due to free-riding effects on low risk of infection, making their impact on vaccination uptake ambiguous. We develop a theoretical framework to capture heterogeneity around vaccination behaviors, and empirically measure the causal effects of different messages about vaccination coverage rates on four self-reported and behavioral vaccination intention measures. In an online experiment, N = 1365 UK adults are randomly assigned to one of seven treatment groups with different messages about their social environment's coverage rate (varied between 10% and 95%), or a control group with no message. We find that treated groups have significantly greater vaccination intention than the control. Treatment effects increase with the coverage rate up to a 75% level, consistent with a bandwagoning effect. For coverage rates above 75%, the treatment effects, albeit still positive, stop increasing and remain flat (or even decline). Our results suggest that, at higher coverage rates, free-riding behavior may partially crowd out bandwagoning effects of coverage rate messages. We also find significant heterogeneity of these effects depending on the individual perceptions of risks of infection and of the coverage rates.

Influenza-Related Knowledge, Beliefs, and Experiences Among Caregivers of Hospitalized Children

OBJECTIVE

Caregivers frequently decline influenza vaccine for their hospitalized child. In this study, we aimed to examine factors impacting their influenza vaccine decision-making.

METHODS

We conducted a cross-sectional survey study of English- and Spanish-speaking caregivers of children hospitalized at a tertiary care pediatric hospital between November 2017 and April 2018. The survey assessed influenza-related knowledge, beliefs, experiences, and vaccine hesitancy. Multivariable logistic regression examined associations between survey responses and child influenza vaccination status at admission (already vaccinated versus not yet vaccinated this season) and, among caregivers with vaccine-eligible children, influenza vaccine acceptance (versus declination) for their child during hospitalization.

RESULTS

Caregivers (N =522; 88.9% response rate) were mostly non-Hispanic white (66.9%) and English-speaking (97.7%). At admission, 63.2% of children were already vaccinated this season. The caregiver view that influenza vaccination is important for their child's health was the strongest positive predictor of having an already vaccinated child (adjusted odds ratio [aOR]: 3.16; 95% confidence interval [CI]: 2.46-4.05); vaccine hesitancy was the strongest negative predictor (aOR: 0.61; 95% CI: 0.50-0.75). Among caregivers with vaccine-eligible children, 30.3% accepted influenza vaccine for their hospitalized child. Their belief regarding the child health benefits of influenza vaccination was associated with vaccine acceptance during hospitalization (aOR: 6.87; 95% CI: 3.38-13.96). Caregiver vaccine hesitancy and agreement that children with mild illness should delay vaccination negatively impacted vaccine acceptance (aOR: 0.39; 95% CI: 0.25-0.62; aOR: 0.33; 95% CI: 0.20-0.56, respectively).

CONCLUSIONS

We identified key factors impacting influenza vaccine decision-making among caregivers of hospitalized children, a critical step to improving uptake in this population.

Resources for assessing parents' vaccine hesitancy: a systematic review of the literature

The concept of Vaccine Hesitancy has begun to appear in the scientific landscape, referring to the reluctance of a growing proportion of people to accept the vaccination offer. A variety of factors were identified as being associated with vaccine hesitancy but there was no universal algorithm and currently there aren’t any established metrics to assess either the presence or impact of vaccine hesitancy. The aim of this study was to systematically review the published questionnaires evaluating parental vaccine hesitancy, to highlight the differences among these surveys and offer a general overview on this matter. This study offers a deeper perspective on the available questionnaires, helping future researches to identify the most suitable one according to their own aim and study setting.

Partnering with parents to remove barriers and improve influenza immunization rates for young children

BACKGROUND

Despite the ongoing public health initiatives to increase pediatric influenza immunization rates to 80%, only a few US health centers have been able to meet this goal. The suboptimal immunity to influenza poses individual and societal risks for vaccine-preventable cases of influenza and its complications.

LOCAL PROBLEM

At a diverse, urban, family health center, its influenza immunization rate of 44% represented the lowest uptake rate compared with all other early childhood vaccines, increasing the risk of morbidity and mortality in young children, including hospitalization and death.

METHODS

To identify key barriers to influenza immunization, the investigators interviewed parents of children aged 6 through 24 months at this urban family health center via randomized sampling using an open-ended telephone survey.

INTERVENTIONS

Based on the concerns parents expressed through the survey, a program was designed and implemented that included reminder calls, parent education, proactive appointment scheduling, and social media reminders.

RESULTS

After implementing a parent-driven quality-improvement program for 6 months during influenza season, the health center's pediatric influenza immunization rates rose to 57% compared with 44% during the year before.

CONCLUSIONS

Childhood immunization is a critical priority to protect the health and wellness of children. Increasing parent engagement in discussions about increasing immunization rates not only promotes awareness surrounding vaccines but also allows primary care providers to learn from parents to create a patient-centered immunization program. Programs that specifically target immunization efforts toward parental concerns have the potential for increased vaccine acceptance and improved health outcomes.

Parental Perception Towards Flu Vaccination for Asthmatic Children in Saudi Arabia

Background  Asthma is a major noncommunicable disease that affects around 235 million people, including children, globally. In the Kingdom of Saudi Arabia (KSA), the incidence of childhood asthma continues to increase. The Ministry of Health in Saudi Arabia has attempted to put policies in place to prevent the occurrence of asthma-related complications by encouraging parents to vaccinate their diagnosed asthmatic children with the flu vaccine. To date, however, there have been no studies investigating the use of flu vaccine among asthmatic children in KSA. Our research aims to explore the perception of parents with asthmatic children towards flu vaccination and its effect on the decision to vaccinate their children. Methods Our research was a cross-sectional study of 190 parents who presented with asthmatic children at King Fahad Medical City (KFMC) in Riyadh, KSA from October 2016 to April 2017. The study tools included structured and semi-structured questionnaires with demographic information, types of healthcare, and perceptions of parents towards flu vaccination. Data analysis was done using Statistical Package for the Social Sciences (SPSS; IBM, Armonk, NY). Results Samples were mostly Saudis (97%), who were married (92%), and in the age group of 21-40 years (70%). Most of them were females (59%). More than two-thirds of the parents had a middle school education or bachelor's degree, and more than half were employed. Parents with higher education had a higher rate of vaccination for their children, and they were more likely to believe that a non-vaccinated child is more likely to get flu. Almost 76% of parents with vaccinated children agreed that the flu vaccine could safeguard children against flu. Doctors' opinion about flu vaccination was significantly associated with the parents' decision. The multivariate regression analysis results showed that easy access to services and parents' beliefs regarding vaccination are positively associated with influenza vaccination status. Conclusion Among the essential factors positively associated with the influenza vaccination status were a perception of easy access to vaccination services and the belief that non-vaccinated children are more likely to contract the flu virus. In contrast, the belief that vaccination prevents infection by the flu virus was negatively associated with vaccine uptake.

School-Located Influenza Vaccination: Do Vaccine Clinics at School Raise Vaccination Rates?

BACKGROUND

Only half of US schoolchildren receive influenza vaccine. School-located influenza vaccination (SLIV) might raise vaccination rates but conducting flu vaccine clinics at schools is challenging to implement. We compared 2 school-based programs designed to raise influenza vaccination rates: parent reminder/educational messages sent to parents from schools which is a low-intensity intervention vs the combination of reminder/educational messages plus SLIV clinics which is a high-intensity intervention.

METHODS

We assigned 36 schools (6 school districts, 2 per group) to 3 groups: (1) control, ie, no SLIV and no parent reminder/education, (2) parent reminder/education emailed by schools, and (3) parent reminder/education plus SLIV clinics. Some schools had SLIV clinics in prior years. Health department nurses conducted SLIV clinics.

RESULTS

Among 24,832 children at 36 schools, vaccination rates were control (51.3%), parent reminder/education-only (41.2%), and reminder/education + SLIV (58.7%). On multivariate analyses which controlled for vaccination in prior seasons, children in reminder/education + SLIV schools had higher vaccination rates (OR 1.27, 95% CI 1.10-1.47), but children in reminder/education-only schools had lower rates (OR 0.87, 95% CI 0.75-1.00) than children in control schools.

CONCLUSIONS

Parent reminder/education combined with SLIV clinics raise vaccination rates, but parent reminder/education alone does not.

Evaluating Interventions to Increase Influenza Vaccination Rates among Pediatric Inpatients

Introduction:

Hospitalization provides an ideal opportunity for influenza vaccination, and strategies can enhance existing tools within the electronic medical record (EMR). The objectives of the study were to introduce and evaluate the effectiveness of provider and family-directed interventions to increase influenza vaccination ordering among inpatients.

Methods:

We conducted a quality improvement initiative for children aged older than 6 months on medical inpatient teams at a large pediatric tertiary care hospital from September 2014 to March 2015, comprising 2 intervention groups (provider reminders and family education) and 1 control group for comparison, using EMR prompts alone. The provider reminder interventions comprised weekly e-mails indicating inpatient immunization status; vaccination reports; and visual reminders. The family education group intervention consisted of handouts regarding the benefits and safety of influenza vaccination. We measured vaccine ordering rates for each group among eligible children and overall vaccination rates. Data were analyzed using Statistical Process Control Charts and Chi-square tests.

Results:

Among 2,552 patients aged older than 6 months hospitalized during the study period, 1,657 were unimmunized. During the intervention period, the provider group ordered 213/409 (52%) influenza vaccines, the family education group ordered 138/460 (30%) and the control group ordered 71/279 (25%) (P < 0.0001). The provider group had higher influenza immunization status than the control group (61% versus 53%; P = 0.0017). Exposure to the intervention did not impact the length of stay/discharge time.

Conclusions:

Provider reminders including e-mails, visual reminders, and vaccination reports are effective ways of increasing inpatient influenza vaccination rates and are more effective than family education, or EMR prompts alone.

Increasing influenza vaccine uptake in children: A randomised controlled trial

BACKGROUND

Influenza vaccine is not included in the Hong Kong Government's universal Childhood Immunisation Programme but eligible children can receive subsidised vaccine through the private sector using the Vaccination Subsidy Scheme (VSS). This study examined whether a simple intervention package can increase influenza vaccine uptake in Hong Kong children.

METHODS

Two study samples were enrolled: families of children who had participated in a previous knowledge, attitudes and practices study; and mother-infant pairs recruited from postnatal wards. Control groups received publicly available leaflets about VSS. Intervention groups additionally received: (1) a concise information sheet about influenza and its vaccine; (2) semi-completed forms to utilise the subsidy; (3) contacts of VSS clinics that did not charge above the subsidy; and (4) text message reminders for vaccination. Enrolled mothers were contacted when children were approximately 1 and 2 years old to determine influenza vaccination status of the families and their plan to vaccinate their children. Mothers' attitudes towards influenza vaccine were assessed at enrolment and at the end of the study.

RESULTS

A total of 833 eligible mother-infant pairs were enrolled from the two samples. The intervention package improved influenza vaccine uptake by 22% at one year and 25% at two years of age. Maternal influenza vaccine uptake in intervention group was higher during this two-year period in those who had never been previously vaccinated. Mothers' self-efficacy regarding the use of influenza vaccine in her child i.e. belief and confidence in her own ability to make a good decision, was also improved with the intervention.

CONCLUSIONS

A four-component intervention package could improve influenza vaccine uptake in Hong Kong children and their mothers during the first two years of life and depending on vaccine effectiveness could potentially reduce influenza-associated hospital admissions in children below 2 years old by 13-24%.

School-located Influenza Vaccinations for Adolescents: A Randomized Controlled Trial

PURPOSE

We aimed to evaluate the effect of school-located influenza vaccination (SLIV) on adolescents' influenza vaccination rates.

METHODS

In 2015-2016, we performed a cluster-randomized trial of adolescent SLIV in middle/high schools. We selected 10 pairs of schools (identical grades within pairs) and randomly allocated schools within pairs to SLIV or usual care control. At eight suburban SLIV schools, we sent parents e-mail notifications about upcoming SLIV clinics and promoted online immunization consent. At two urban SLIV schools, we sent parents (via student backpack fliers) paper immunization consent forms and information about SLIV. E-mails were unavailable at these schools. Local health department nurses administered nasal or injectable influenza vaccine at dedicated SLIV clinics and billed insurers. We compared influenza vaccination rates at SLIV versus control schools using school directories to identify the student sample in each school. We used the state immunization registry to determine receipt of influenza vaccination.

RESULTS

The final sample comprised 17,650 students enrolled in the 20 schools. Adolescents at suburban SLIV schools had higher overall influenza vaccination rates than did adolescents at control schools (51% vs. 46%, p < .001; adjusted odds ratio = 1.27, 95% confidence interval 1.18-1.38, controlling for vaccination during the prior two seasons). No effect of SLIV was noted among urbanschools on multivariate analysis. SLIV did not substitute for vaccinations in primary care or other settings; in suburban settings, SLIV was associated with increased vaccinations in primary care or other settings (adjusted odds ratio = 1.10, 95% confidence interval 1.02-1.19).

CONCLUSIONS

SLIV in this community increased influenza vaccination rates among adolescents attending suburban schools.

The influence of social norms on flu vaccination among African American and White adults

Adult influenza vaccination rates remain suboptimal, particularly among African Americans. Social norms may influence vaccination behavior, but little research has focused on influenza vaccine and almost no research has focused on racially-specific norms. This mixed methods investigation utilizes qualitative interviews and focus groups (n = 118) and national survey results (n = 1643) to assess both descriptive and subjective norms surrounding influenza vaccination. Qualitative results suggest a perceived descriptive norm that 'about half' of the population gets vaccinated. Participants describe differing norms by race and vaccine behavior. Quantitative results confirm a perceived descriptive norm that 40-60% of the population gets vaccinated. Both African Americans and Whites accurately identified race-specific vaccination rates relative to the general population. Individuals who report that a majority of people around them want them to be vaccinated were significantly more likely to be vaccinated, suggesting subjective norms are influential for both White and African American adults. While perceived descriptive norms are somewhat accurate (mirroring the actual influenza vaccination rate), emphasizing a suboptimal vaccination rate may not be beneficial. Health promotion efforts, particularly those targeting African Americans, may benefit from focusing on subjective norms and encouraging friends and family members to talk about the benefits of influenza vaccination.

Psychosocial Influences on Parental Decision-Making Regarding Vaccination Against Seasonal Influenza for Young Children in Hong Kong: a Longitudinal Study, 2012-2013

PURPOSE

Vaccination uptake remained low, although annual subsidies are provided to encourage 6-72-month-old Hong Kong children to be vaccinated against seasonal influenza. This study was aimed to investigate the psychosocial influences on parental decision-making regarding young children's seasonal influenza vaccination.

METHODS

One-thousand two-hundred twenty-six parents of eligible children were recruited using random digit dialing in August-October 2012 to assess baseline perceptions and re-contacted in March 2013 to record children's vaccination uptake. Structural equation modeling (SEM) was performed to examine factors associated with parental decision about children's vaccination based on the complete data of 1222 respondents.

RESULTS

Of the 1226 respondents who completed the follow-up survey, 34.3 % reported that their child was vaccinated during the follow-up period. Child's past influenza vaccination history (β = 0.48), belief in vaccination safety (β = 0.35), and social norms (β = 0.25) were strongly associated with parental intention to vaccinate their child which directly predicted child vaccination uptake (β = 0.57). Belief in vaccination safety (β = 0.42) and social norms (β = 0.36) were strongly associated with vaccination intention of parents whose children never received influenza vaccine.

CONCLUSION

Interventions that address concerns on vaccination safety and utilize social norms may be effective to initiate Chinese parents to vaccinate their children.

An integrative review on parents' perceptions of their children's vaccinations

An integrative literature review was conducted for studies published between January 2005 and January 2016 to obtain evidence on parents' experiences and perceptions of vaccinations. Considering the mandatory nature of vaccinations in many countries and the influences of parental experiences on the outcome of vaccinations, it is essential to understand the experiences and needs of parents regarding their children's vaccinations. CINAHL, PsycINFO, PubMed, Scopus and ScienceDirect were searched for data. In this review, 20 studies (10 quantitative and 10 qualitative) that related to parental perceptions regarding their child's vaccination were included. The parents had varied views on vaccination and they had many vaccination-related concerns and difficulties. Different factors influenced their vaccination decisions and they had varied support needs. This review found that exploring parental perceptions regarding their child's vaccination in terms of the attitudes and experiences of parents, how these affect vaccination decisions as well as the needs of parents regarding their children's vaccinations is important in multicultural societies.

Reasons for non-vaccination: Parental vaccine hesitancy and the childhood influenza vaccination school pilot programme in England

INTRODUCTION

In 2013, the annual influenza immunisation programme in England was extended to children to reduce the burden of influenza, but uptake was sub-optimal at 53.2%.

AIM

To explore the reasons some parents decided not to vaccinate their child against influenza as part of the pilot programme offered in schools.

METHODS

Cross-sectional qualitative study conducted between February and July 2015. 913 parents whose children were not vaccinated against influenza in the school pilots in West Yorkshire and Greater Manchester, England, were asked to comment on their reasons for non-vaccination and invited to take part in a semi-structured interview. 138 parents returned response forms, of which 38 were eligible and interested in participating and 25 were interviewed. Interview transcripts were coded by theme in NVivo.

RESULTS

A third of parents who returned response forms had either vaccinated their child elsewhere, intended to have them vaccinated, or had not vaccinated them due to medical reasons (valid or perceived). Most interviewees were not convinced of the need to vaccinate their child against influenza. Parents expressed concerns about influenza vaccine effectiveness and vaccine side effects. Several parents interviewed declined the vaccine for faith reasons due to the presence of porcine gelatine in the vaccine.

CONCLUSIONS

To significantly decrease the burden of influenza in England, influenza vaccination coverage in children needs to be >60%. Hence, it is important to understand the reasons why parents are not vaccinating their children, and to tailor the communication and immunisation programme accordingly. Our finding that a third of parents, who did not consent to their child being vaccinated as part of the school programme, had actually vaccinated their child elsewhere, intended to have their child vaccinated, or had not vaccinated them due to medical reasons, illustrates the importance of including additional questions or data sources when investigating under-vaccination.

The impact of an educational intervention on parents' decisions to vaccinate their <60-month-old children against influenza

Purpose

Seasonal influenza can be prevented by vaccination. Disease prevention in children aged <60 months is of particular importance because of the associated familial and societal burden. Considering that caretakers make the decision to vaccinate their children, the identification of drivers and barriers to vaccination is essential to increase influenza vaccination coverage.

Methods

A total of 639 parents participated in the pre- and posteducational survey and 450 parents participated in the study via telephone interviews. The participating parents were asked to rank their agreement with each statement of the survey questionnaire on a scale from 1 (strongly disagree) to 5 (strongly agree), and the scores between pre- and postintervention were compared.

Results

Before the educational intervention, 105 out of 639 participants reported not to agree to vaccinate their children against influenza. After the intervention, 46 out of the 105 parents changed their opinions about childhood vaccination. The physicians' recommendation received the highest agreement score and was the most important driver to vaccination, whereas the cost of vaccination was the strongest factor for not vaccinating children. In general, the participants significantly changed the agreement scores between pre- and postintervention. However, the unfavorable opinions about vaccination and the convenience of receiving the influenza vaccine did not change significantly.

Conclusion

The results of this study indicate that a specific educational intervention involving caregivers is very effective in increasing the influenza vaccination coverage of children aged less than 60 months.

Barriers of Influenza Vaccination Intention and Behavior - A Systematic Review of Influenza Vaccine Hesitancy, 2005 - 2016

BACKGROUND

Influenza vaccine hesitancy is a significant threat to global efforts to reduce the burden of seasonal and pandemic influenza. Potential barriers of influenza vaccination need to be identified to inform interventions to raise awareness, influenza vaccine acceptance and uptake.

OBJECTIVE

This review aims to (1) identify relevant studies and extract individual barriers of seasonal and pandemic influenza vaccination for risk groups and the general public; and (2) map knowledge gaps in understanding influenza vaccine hesitancy to derive directions for further research and inform interventions in this area.

METHODS

Thirteen databases covering the areas of Medicine, Bioscience, Psychology, Sociology and Public Health were searched for peer-reviewed articles published between the years 2005 and 2016. Following the PRISMA approach, 470 articles were selected and analyzed for significant barriers to influenza vaccine uptake or intention. The barriers for different risk groups and flu types were clustered according to a conceptual framework based on the Theory of Planned Behavior and discussed using the 4C model of reasons for non-vaccination.

RESULTS

Most studies were conducted in the American and European region. Health care personnel (HCP) and the general public were the most studied populations, while parental decisions for children at high risk were under-represented. This study also identifies understudied concepts. A lack of confidence, inconvenience, calculation and complacency were identified to different extents as barriers to influenza vaccine uptake in risk groups.

CONCLUSION

Many different psychological, contextual, sociodemographic and physical barriers that are specific to certain risk groups were identified. While most sociodemographic and physical variables may be significantly related to influenza vaccine hesitancy, they cannot be used to explain its emergence or intensity. Psychological determinants were meaningfully related to uptake and should therefore be measured in a valid and comparable way. A compendium of measurements for future use is suggested as supporting information.

School-Located Influenza Vaccinations: A Randomized Trial

OBJECTIVE

Assess impact of offering school-located influenza vaccination (SLIV) clinics using both Web-based and paper consent upon overall influenza vaccination rates among elementary school children.

METHODS

We conducted a cluster-randomized trial (stratified by suburban/urban districts) in upstate New York in 2014-2015. We randomized 44 elementary schools, selected similar pairs of schools within districts, and allocated schools to SLIV versus usual care (control). Parents of children at SLIV schools were sent information and vaccination consent forms via e-mail, backpack fliers, or both (depending on school preferences) regarding school vaccine clinics. Health department nurses conducted vaccine clinics and billed insurers. For all children registered at SLIV/control schools, we compared receipt of influenza vaccination anywhere (primary outcome).

RESULTS

The 44 schools served 19 776 eligible children in 2014-2015. Children in SLIV schools had higher influenza vaccination rates than children in control schools county-wide (54.1% vs 47.4%, P < .001) and in suburban (61.9% vs 53.6%, P < .001) and urban schools (43.9% vs 39.2%; P < .001). Multivariate analyses (controlling for age, grade, vaccination in previous season) confirmed bivariate findings. Among parents who consented for SLIV, nearly half of those notified by backpack fliers and four-fifths of those notified by e-mail consented online. In suburban districts, SLIV did not substitute for primary care influenza vaccination. In urban schools, some substitution occurred.

CONCLUSIONS

SLIV raised seasonal influenza vaccination rates county-wide and in both suburban and urban settings. SLIV did not substitute for primary care vaccinations in suburban settings where pediatricians often preorder influenza vaccine but did substitute somewhat in urban settings.

Influenza knowledge, attitude, and behavior survey for grade school students: design and novel assessment methodology

Despite the fact infectious diseases can spread readily in grade schools, few studies have explored prevention in this setting. Additionally, we lack valid tools for students to self-report knowledge, attitudes, and behaviors. As part of an ongoing study of a curriculum intervention to promote healthy behaviors, we developed and evaluated age-appropriate surveys to determine students' understanding of influenza prevention. Surveys were adapted from adolescent and adult influenza surveys and administered to students in grades 2-5 (ages 7-11) at two Rochester public schools. We assessed student understanding by analyzing percent repeatability of 20 survey questions and compared percent "don't know" (DK) responses across grades, gender, and race. Questions thought to be ambiguous after early survey administration were investigated in student focus groups, modified as appropriate, and reassessed. The response rate across all surveys was >87%. Survey questions were well understood; 16 of 20 questions demonstrated strong pre/post repeatability (>70%). Only 1 question showed an increase in DK response for higher grades (p < .0001). Statistical analysis and qualitative feedback led to modification of 3 survey questions and improved measures of understanding in the final survey administration. Grade-school students' knowledge, attitudes and behavior toward influenza prevention can be assessed using surveys. Quantitative and qualitative analysis may be used to assess participant understanding and refine survey development for pediatric survey instruments. These methods may be used to assess the repeatability and validity of surveys to assess the impact of health education interventions in young children.

Influence of sources of information about influenza vaccine on parental attitudes and adolescent vaccine receipt

In 2011-2012, only 34% of 13-17 years olds in the United States (US) received seasonal influenza vaccine. Little is known about the link between parents' sources of health information, their vaccine-related attitudes, and vaccination of their adolescent against influenza. This study seeks to determine the relationship between number of sources of information on influenza vaccine, parental attitudes toward influenza vaccine, and influenza vaccine uptake in adolescents. We conducted a telephone and web-based survey among US parents of students enrolled in 6 middle and 5 high schools in Georgia. Bivariate and multivariable analyses were conducted to examine associations between the number of information sources about influenza vaccine and vaccine receipt and whether parent vaccine-related attitudes act as a mediator. The most commonly reported sources of information were: a physician/medical professional (95.0%), a family member or friend (80.6%), and television (77.2%). Parents who had higher attitude scores toward influenza vaccine were 5 times as likely to report their adolescent had ever received influenza vaccine compared to parents who had lower attitude scores (adjusted odds ratio (aOR) 5.1; 95% confidence intervals (CI) 3.1-8.4; P < 0.01). Parent vaccine-related attitudes were a significant mediator of the relationship between sources of information and vaccine receipt. In light of the low response rate and participation in an adolescent vaccination intervention, findings may not be generalizable to other populations. This study shows the importance of multiple sources of information in influencing parental decision-making about influenza vaccine for adolescents. Harnessing the power of mass media and family members and friends as health advocates for influenza vaccination can potentially help increase vaccination coverage of adolescents.

Influenza Vaccine Effectiveness and Uptake in Children at Risk of Severe Disease

BACKGROUND

Data demonstrating the effectiveness of inactivated trivalent influenza vaccine (TIV) for children at increased risk of severe disease are limited. Our objective was to determine the effectiveness of TIV in children with risk factors for severe disease and to compare vaccine uptake, parental attitudes and prescriber recommendations in children with and without risk factors for severe disease.

METHODS

Children aged 6-59 months presenting for emergency care (2008 to 2014) with an influenza-like illness were eligible. Influenza polymerase chain reaction/culture was performed on nasopharyngeal samples. Vaccination status was confirmed via the national register and/or vaccine providers. The test-negative design was used to estimate vaccine effectiveness (VE). Risk factors, parental attitudes and prescriber recommendations were assessed by parental questionnaire.

RESULTS

Two thousand seven hundred twenty-three children were recruited. Risk factors for severe disease included comorbid medical conditions (11.6%), preterm birth (13.0%) and indigeneity (5.0%). Influenza was identified in 546 (20.1%) participants. Overall VE (2008 and 2010 to 2014) was 70.0% (95% confidence interval: 47.7 to 82.9); VE for children with medical comorbidities, children born preterm and children <2 years were 82.5% (14.6 to 96.4), 79.2% (10.9 to 95.1) and 84.7% (49.6 to 95.3), respectively. After adverse events in 2010, the number of children fully vaccinated with TIV declined significantly. This included children with and without risk factors for severe disease. Attitudes were similar in parents of children with and without risk factors for severe disease.

CONCLUSIONS

VE for TIV in young children with and without risk factors for severe disease was ≥70%. Despite this, participation in the preschool influenza vaccination program remains low with parents and prescribers unconvinced of the benefits and safety of TIV.

Parents' perception and their decision on their children's vaccination against seasonal influenza in Guangzhou

BACKGROUND

Seasonal influenza epidemic occurs every year in Guangzhou, which can affect all age groups. Young children are the most susceptible targets. Parents can decide whether to vaccinate their children or not based on their own consideration in China. The aim of this study was to identify factors that are important for parental decisions on vaccinating their children against seasonal influenza based on a modified health belief model (HBM).

METHODS

A cross-sectional study was conducted in Guangzhou, China. A total of 335 parents who had at least on child aged between 6 months and 3 years were recruited from women and children's hospital in Guangzhou, China. Each eligible subject was invited for a face-to-face interview based on a standardized questionnaire.

RESULTS

Uptake of seasonal influenza within the preceding 12 months among the target children who aged between 6 months and 36 months was 47.7%. Around 62.4% parents indicated as being "likely/very likely" to take their children for seasonal influenza vaccination in the next 12 months. The hierarchical logistic regression model showed that children's age (odds ratio [OR] =2.59, 95% confidence interval [CI]: 1.44-4.68), social norm (OR = 2.08, 95% CI: 1.06-4.06) and perceived control (OR = 2.96, 95% CI: 1.60-5.50) were significantly and positively associated with children's vaccination uptake within the preceding 12 months; children with a history of taking seasonal influenza vaccine (OR = 2.50, 95% CI: 1.31-4.76), perceived children's health status (OR = 3.36, 95% CI: 1.68-6.74), worry/anxious about their children influenza infection (OR = 2.31, 95% CI: 1.19-4.48) and perceived control (OR = 3.21, 95% CI: 1.65-6.22) were positively association with parental intention to vaccinate their children in the future 12 months. However, anticipated more regret about taking children for the vaccination was associated with less likely to vaccinate children within the preceding 12 months (OR = 0.21, 95% CI: 0.08-0.52).

CONCLUSIONS

The modified HBM provided a good theoretical basic for understanding factors associated with parents' decisions on their children's vaccination against seasonal influenza.

Urban and Rural Differences in Parental Attitudes About Influenza Vaccination and Vaccine Delivery Models

OBJECTIVES

To assess and compare among parents of healthy children in urban and rural areas: (1) reported influenza vaccination status; (2) attitudes regarding influenza vaccination; and (3) attitudes about collaborative models for influenza vaccination delivery involving practices and public health departments.

METHODS

A mail survey to random samples of parents from 2 urban and 2 rural private practices in Colorado from April 2012 to June 2012.

RESULTS

The response rate was 58% (288/500). In the prior season, 63% of urban and 41% of rural parents reported their child received influenza vaccination (P < .001). No differences in attitudes about influenza infection or vaccination between urban and rural parents were found, with 75% of urban and 73% of rural parents agreeing their child should receive an influenza vaccine every year (P = .71). High proportions reported willingness to participate in a collaborative clinic in a community setting (59% urban, 70% rural, P = .05) or at their child's provider (73% urban, 73% rural, P = .99) with public health department assisting. Fewer (36% urban, 53% rural, P < .01) were likely to go to the public health department if referred by their provider. Rural parents were more willing for their child to receive vaccination outside of their provider's office (70% vs. 55%, P = .01).

CONCLUSIONS

While attitudes regarding influenza vaccination were similar, rural children were much less likely to have received vaccination. Most parents were amenable to collaborative models of influenza vaccination delivery, but rural parents were more comfortable with influenza vaccination outside their provider's office, suggesting that other venues for influenza vaccination in rural settings should be promoted.

Vaccinating sons against HPV: results from a U.S. national survey of parents

Purpose

The quadrivalent HPV vaccination was approved for use in males ages 9 to 26 in 2009 and recommended for routine administration in 2011. The purpose of this study was to uncover predictable commonalities amongst parents who chose to vaccinate their 11–17 year old sons against HPV.

Methods

We compiled data from a U.S. national sample of 779 parents with sons 11–17 years old using a web-based survey to gather information about behavioral and sociodemographic factors which predicted receipt of 1 or more HPV vaccine doses based on parental report. Predictors were first modeled individually for univariable associations. Significant predictors (p<0.10) were combined in a multivariable model.

Results

In the adjusted model, independent predictors included receipt of flu vaccination, health insurance coverage and sexual health topic discussions with sons. Sons who had received a flu shot in the last two years more frequently received at least one dose of the vaccine (OR 1.82; 95% CI 1.45–2.26). Sons covered by private health insurance had decreased odds of HPV vaccination (OR 0.56 95% CI 0.37–0.83). Lastly, parents who had discussed sexual health topics with their sons were more likely to vaccinate (OR 1.61; 95% CI 1.37–1.89).

Conclusions

Male vaccination rates in the U.S. have increased, but males continue to be under-immunized. Utilization of health care is an important factor in HPV vaccine uptake; therefore, health care providers should use every contact as an opportunity to vaccinate. Communication about sexual health topics may provide a forum for parents and health care providers to have conversations about HPV vaccination as those more comfortable discussing these topics may also be more comfortable discussing HPV vaccination.

Cognitive biases and heuristics in medical decision making: a critical review using a systematic search strategy

BACKGROUND

The role of cognitive biases and heuristics in medical decision making is of growing interest. The purpose of this study was to determine whether studies on cognitive biases and heuristics in medical decision making are based on actual or hypothetical decisions and are conducted with populations that are representative of those who typically make the medical decision; to categorize the types of cognitive biases and heuristics found and whether they are found in patients or in medical personnel; and to critically review the studies based on standard methodological quality criteria.

METHOD

Data sources were original, peer-reviewed, empirical studies on cognitive biases and heuristics in medical decision making found in Ovid Medline, PsycINFO, and the CINAHL databases published in 1980-2013. Predefined exclusion criteria were used to identify 213 studies. During data extraction, information was collected on type of bias or heuristic studied, respondent population, decision type, study type (actual or hypothetical), study method, and study conclusion.

RESULTS

Of the 213 studies analyzed, 164 (77%) were based on hypothetical vignettes, and 175 (82%) were conducted with representative populations. Nineteen types of cognitive biases and heuristics were found. Only 34% of studies (n = 73) investigated medical personnel, and 68% (n = 145) confirmed the presence of a bias or heuristic. Each methodological quality criterion was satisfied by more than 50% of the studies, except for sample size and validated instruments/questions. Limitations are that existing terms were used to inform search terms, and study inclusion criteria focused strictly on decision making.

CONCLUSIONS

Most of the studies on biases and heuristics in medical decision making are based on hypothetical vignettes, raising concerns about applicability of these findings to actual decision making. Biases and heuristics have been underinvestigated in medical personnel compared with patients.

School-located influenza vaccination with third-party billing: what do parents think?

OBJECTIVE

School-located influenza vaccination (SLIV) may be instrumental in achieving high vaccination rates among children. Sustainability of SLIV programs may require third-party billing. This study assessed, among parents of elementary school students, the attitudes about SLIV and billing at school, as well as factors associated with being supportive of SLIV.

METHODS

We conducted a survey (April 2010 to June 2010) of parents of 1000 randomly selected primarily low-income children at 20 elementary schools at which SLIV with billing had occurred.

RESULTS

Response rate was 70% (n = 699). Eighty-one percent agreed (61% strongly) they "would be okay" with SLIV for their child. Many agreed it was better to get vaccinated at their child's doctor's office because they could take care of other health issues (72%) and the doctor knows the child's medical history (65%). However, an equal percentage (47%) thought the best place for influenza vaccination was the child's doctor's office and the child's school. Twenty-five percent did not want to give health insurance information necessary for billing at school. Factors independently associated with strongly supporting SLIV included parental education of high school or less (relative risk 1.30; 95% confidence interval 1.09-1.58), Hispanic ethnicity (1.25; 1.08-1.45); believing the vaccine is efficacious (1.49; 1.23-1.84); and finding school delivery more convenient (2.37; 1.82-3.45). Having concerns about the safety of influenza vaccine (0.80; 0.72-0.88) and not wanting their child to be vaccinated without a parent (0.74; 0.64-0.83) were negatively associated.

CONCLUSIONS

The majority of parents were supportive of SLIV, although parental concerns about not being present for vaccination and about the safety and efficacy of the vaccine will need to be addressed.

Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: a systematic review of published literature, 2007-2012

Vaccine "hesitancy" is an emerging term in the literature and discourse on vaccine decision-making and determinants of vaccine acceptance. It recognizes a continuum between the domains of vaccine acceptance and vaccine refusal and de-polarizes previous characterization of individuals and groups as either anti-vaccine or pro-vaccine. The primary aims of this systematic review are to: 1) identify research on vaccine hesitancy; 2) identify determinants of vaccine hesitancy in different settings including its context-specific causes, its expression and its impact; and 3) inform the development of a model for assessing determinants of vaccine hesitancy in different settings as proposed by the Strategic Advisory Group of Experts Working Group (SAGE WG) for dealing with vaccine hesitancy. A broad search strategy, built to capture multiple dimensions of public trust, confidence and hesitancy around vaccines, was applied across multiple databases. Peer-reviewed studies were selected for inclusion if they focused on childhood vaccines [≤ 7 years of age], used multivariate analyses, and were published between January 2007 and November 2012. Our results show a variety of factors as being associated with vaccine hesitancy but they do not allow for a complete classification and confirmation of their independent and relative strength of influence. Determinants of vaccine hesitancy are complex and context-specific - varying across time, place and vaccines.

Influenza-associated pediatric deaths in the United States, 2004-2012

BACKGROUND

Influenza-associated deaths in children occur annually. We describe the epidemiology of influenza-associated pediatric deaths from the 2004-2005 through the 2011-2012 influenza seasons.

METHODS

Deaths in children <18 years of age with laboratory-confirmed influenza virus infection were reported to the Centers for Disease Control and Prevention by using a standard case report form to collect data on demographic characteristics, medical conditions, clinical course, and laboratory results. Characteristics of children with no high-risk medical conditions were compared with those of children with high-risk medical conditions.

RESULTS

From October 2004 through September 2012, 830 pediatric influenza-associated deaths were reported. The median age was 7 years (interquartile range: 1-12 years). Thirty-five percent of children died before hospital admission. Of 794 children with a known medical history, 43% had no high-risk medical conditions, 33% had neurologic disorders, and 12% had genetic or chromosomal disorders. Children without high-risk medical conditions were more likely to die before hospital admission (relative risk: 1.9; 95% confidence interval: 1.6-2.4) and within 3 days of symptom onset (relative risk: 1.6; 95% confidence interval: 1.3-2.0) than those with high-risk medical conditions.

CONCLUSIONS

Influenza can be fatal in children with and without high-risk medical conditions. These findings highlight the importance of recommendations that all children should receive annual influenza vaccination to prevent influenza, and children who are hospitalized, who have severe illness, or who are at high risk of complications (age <2 years or with medical conditions) should receive antiviral treatment as early as possible.

Coverage and parental perceptions of influenza vaccination among parents of children aged 6 to 23 months in Hong Kong

BACKGROUND

The impact of influenza on young children can be severe and even fatal. Influenza vaccination (IV) has been shown to be effective in reducing complications of influenza among children. This study investigated the prevalence and factors of IV among children aged 6-23 months in Hong Kong.

METHODS

A sample of 401 Chinese parents of children aged 6-23 months were interviewed at local Maternal and Child Health Centers. Socio-demographic information, variables related to Health Belief Model, including perceptions about the child's chance of contracting influenza, perceived harm of influenza on children, perceived benefits and side-effects of IV, having received recommendations from health professionals to uptake IV, and IV behaviors of the children were measured. Multivariate analysis was used to examine factors associated with IV behaviors of children.

RESULTS

Only 9% of the children had ever been vaccinated. Among those parents who had heard of IV (92.0%), substantial proportions perceived that IV could reduce the risk of influenza-induced complications (70.5%), hospitalization (70.5%) and death (65.9%). Relatively few of the participants believed that IV had no side effects (17.1%) and even less had been recommended by health care professionals to uptake IV (10.6%). Results from multivariate analysis showed that physician recommendations were associated with a higher likelihood for IV among younger children, whilst parental perceptions of the side effects of IV was associated with a lower likelihood for IV.

CONCLUSION

The prevalence of IV among children aged 6-23 months in Hong Kong was very low. Promotion of IV with the component of physician recommendations and parents' knowledge about IV safety for this group is warranted.

A population-level assessment of factors associated with uptake of adolescent-targeted vaccines in Michigan

PURPOSE

Increases in adolescent vaccine coverage are needed. The aim of this study was to identify population-level clinical and demographic factors associated with adolescent vaccination.

METHODS

A retrospective analysis of data from the Michigan Care Improvement Registry (MCIR), a statewide immunization registry, was performed for 2006-2010. The sample included 1,252,655 adolescents aged 11-18 years. Vaccine coverage levels were calculated for tetanus-diphtheria-acellular pertussis (Tdap), meningococcal conjugate (MCV4), flu (seasonal influenza), and human papillomavirus, females only (HPV) vaccines. For the subset of adolescents enrolled in Medicaid, claims data were used to obtain information about the type of visits in which vaccines were administered.

RESULTS

As of 2010, statewide coverage levels for Tdap and MCV4 vaccines were 46.0% and 46.5%, respectively whereas only 15% of females had completed the HPV vaccine series. Only one in four female adolescents were up to date for all three of these vaccines. Statewide coverage among adolescents for flu vaccine during the 2009-2010 season was 8%. Age was the most significant predictor of HPV vaccination, whereas health care-associated factors (provider type and childhood immunization history) were the strongest predictors for the other three vaccines. Older adolescents were less likely to have received the flu vaccine but more likely to have receive HPV vaccine doses than younger adolescents. Among Medicaid-enrolled adolescents, most Tdap, MCV, and first-dose HPV vaccines, but only 29% of flu doses, were administered during preventive visits.

CONCLUSIONS

Noted variability in adolescent vaccine coverage by age, vaccine type, and health care-associated factors provides a framework for developing future outreach activities to increase adolescent vaccine use.

Community-centered education improves vaccination rates in children from low-income households

OBJECTIVE

We partnered with the Salvation Army to educate resource-poor families regarding childhood immunizations in an effort to improve vaccine coverage rates.

METHODS

Eligibility for enrollment included children of families presenting at registration for our Salvation Army holiday gift program, available to families with an annual income <150% of federal poverty guidelines. Parents completed a questionnaire, were provided each child's vaccination status as documented in the New York State Immunization Information System, and interacted with the study team to address immunization-related concerns. Missed vaccines were identified and parents were directed to their child's medical home for necessary immunizations. Vaccine coverage was ascertained via the New York State Immunization Information System every 6 to 8 weeks with telephone follow-up for children who remained delayed. The McNemar test and standard 2-proportion comparison were used to determine confidence intervals when analyzing matched or independent data, respectively.

RESULTS

A total of 1531 children were enrolled; 416 (28%) of the 1477 children with accurate immunization records were vaccine complete. When we excluded influenza vaccine, 1034 (70%) of children had received all other recommended vaccines. Nine months later, vaccine completion rates increased from 28% to 45%, largely because of improvements in influenza vaccination rates, which increased by 17% (confidence interval [CI] 15.5-19.5), a significant improvement over county (8%, 95% CI 7.4-8.1) and statewide (5%, 95% CI 4.7-4.8) rates during the same period.

CONCLUSIONS

Immunization rates in poor children are suboptimal. Partnering with community-based organizations to address parental concerns, provide education, and perform follow-up was effective in improving immunization rates, particularly for influenza vaccine.

Impact of a physician recommendation and parental immunization attitudes on receipt or intention to receive adolescent vaccines

Four vaccines are recommended by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices for adolescents. Parental attitudes may play a key role in vaccination uptake in this age group. In 2011, we conducted a cross-sectional survey among parents of adolescents in one county in Georgia to identify parental attitudes toward adolescent vaccination, reasons for vaccine acceptance or refusal, and impact of a physician recommendation for vaccination. Physician recommendation was reported as one of the top reasons for receipt or intent to receive any of the vaccines. Physician recommendation of any of the four vaccines was associated with receipt of Tdap (p<0.001), MCV4 (p<0.001), and HPV (p = 0.03) and intent to receive Tdap (p = 0.05), MCV4 (p = 0.005), and HPV (p = 0.05). Compared with parents who did not intend to have their adolescent vaccinated with any of the vaccines, parents who did intend reported higher perceived susceptibility (3.12 vs. 2.63, p = 0.03) and severity of disease (3.89 vs. 3.70, p = 0.02) and higher perceived benefit of vaccination (8.48 vs. 7.74, p = 0.02). These findings suggest that future vaccination efforts geared toward parents may benefit from addressing the advantages of vaccination and enhancing social norms. Physicians can play a key role by providing information on the benefits of adolescent vaccination.

Perinatal immunization education improves immunization rates and knowledge: a randomized controlled trial

OBJECTIVES

To determine if providing perinatal immunization education positively changes the immunization status of infants, influences the infant immunization knowledge, attitudes and beliefs of mothers and affects the intent to vaccinate children in Japan where immunization education is limited.

METHODS

Pregnant women were recruited from three sites in Tokyo, Japan and were assigned to two intervention (pre- or postnatal education) groups and a control group. The immunization status of infants was assessed and a written survey was performed before and after the intervention.

RESULTS

Among 119 study participants, 106 subjects replied to the post-survey. The intervention groups (34.3%) had higher immunization rates in infants at three months of age than the control group (8.3%) (P=0.005); however, no differences were observed between the prenatal (29.4%) and postnatal groups (38.9%) (P=0.40). The percentage of women intended to vaccinate their infants was higher in the intervention groups (61.4%) compared to the control group (33.3%) (P=0.01). The improvement in score for basic knowledge was higher in the intervention groups, particularly in the prenatal group (mean±S.D.: 3.4±1.8) compared to the control (1.9±1.9) (P=0.003).

CONCLUSIONS

Perinatal immunization education improved the immunization status of infants, increased the women's knowledge on immunization and intention to vaccinate their infants.

Parental risk perception and influenza vaccination of children in daycare centres

Little information is available about perceptions of influenza vaccination of parents with healthy children in daycare. Therefore, we systematically explored the relationship between parental risk perception and influenza vaccination in children attending daycare. We distributed a self-administered paper survey to parents of children aged 6-59 months attending licensed daycare centres in Tarrant County, Texas. We used conditional logistic regression with penalized conditional likelihood to estimate odds ratios (ORs) and 95% profile likelihood confidence limits (PL) for parental risk-perception factors and influenza vaccination. A high level of parental prevention behaviours (OR 9.1, 95% PL 3.2, 31) and physician recommendation (OR 8.2, 95% PL 2.7, 30) had the highest magnitudes of association with influenza vaccination of healthy children in daycare. Our results provide evidence about critical determinants of influenza vaccination of healthy children in daycare, which could help inform public health interventions aimed at increasing influenza vaccination coverage in this population.

The rate of seasonal influenza vaccination in diabetic children, the effect of recommendation and the factors influencing the acceptance of recommendation: an interventional study

OBJECTIVE

To investigate the vaccination rate of influenza in diabetic children and the effect of recommendation and other factors on vaccination rate.

MATERIAL AND METHODS

On July 2011, 144 diabetic children and their families were informed about and were recommended to receive the influenza vaccine every year, in September. On December 2011, parents were questioned about the vaccination.

RESULTS

Influenza vaccination rate of the previous season (28.3%) increased to 50.0% (p<0.05). Receiving the vaccine in 2010 was the only contributing factor to the recommendation success. The reasons given by the non-receivers were; forgetting (50.0%), fear of adverse-effects (26.4%), not believing in usefulness (15.2%), rejection by the child (4.2%) and effects of media (4.2%). 88.9% of those who forgot declared that they would receive if they were reminded at the beginning of the season.

CONCLUSION

The rate of influenza vaccination was low. The majority of those who didn't recieve the vaccination declared that they would if they were reminded at the beginning of the season and the fact that "receiving the vaccine in 2010" was the only factor influencing the recommendation success indicate that recommending isn't enough but that reminding and giving detailed information about the vaccine will increase vaccination rates independent of other factors.

Governability framework for the evaluation and implementation of complex public health functions

BACKGROUND

The dominant theoretical basis of our public health practice originates from a positivist or reductionist paradigm. It fails to take into account the complexity emerging out of public health's multiple influences originating from biological and social worlds. A deeper understanding of the interaction of elements that characterize the implementation of public health functions will enhance our ability to generate evidence and learn further.

OBJECTIVE

The "interactive governance theory" by Jan Kooiman introduced here offers an analytical framework that uses the concept of "governability." It is a measure of how governable a particular social system is that takes care of a public function. Assessment is facilitated by breaking down and describing the social system into constituent parts and by exploring the properties, qualities, and the way in which they interact with each other. Further, by deliberating a complex public health function such as immunization services in the context of developing countries, we explore the application of the interactive governance theory and governability.

CONCLUSION

The theory offers new insights into how interactive and holistic approaches can be integrated into public health practice. The advantage of the concept of "governability" is that it enables us to explore why some governance systems deliver what they are expected to, while others do not. This might help us to identify areas where governance can be improved.

Correlates of 2009 H1N1 influenza vaccination among day care-aged children, Miami-Dade County

BACKGROUND

The aim of this study was to assess factors influencing 2009 H1N1 influenza vaccination among a demographically diverse group of day care-aged children. Day care children were chosen because they were an initial target group for vaccination and are at higher risk of influenza infection than children cared for at home.

METHODS

A cross-sectional study was conducted from March to May 2010 among parents of day care aged children in 13 day care facilities in Miami-Dade County. Data was collected by an anonymous self-administered two-page 20 question survey which consisted of demographic variables and information regarding 2009 H1N1 influenza vaccine knowledge, attitude and acceptance. Data was analyzed using SAS to conduct both bivariate and multivariate analyses.

RESULTS

There were 773 participants in the study. The response rate ranged from 42% to 72.2% among day care centers. A total of 172 parents (22.3%) and 225 (29.1%) children had received the 2009 H1N1 influenza vaccine. Non-Hispanic White and Black parents were more likely to vaccinate their children than Hispanic and Haitian parents. Primary reasons for non-vaccination included vaccine safety (36.7%) and side effects (27.1%). Among parents who spoke with a health care professional, 274 (61.4%) stated the health care professional recommended the vaccine.

CONCLUSION

Misperceptions about influenza vaccination among parents created a barrier to 2009 H1N1 influenza vaccination. Parents who got the vaccine, who believed the vaccine was safe and whose children had a chronic condition were more likely to immunize their children. Clear, reliable and consistent vaccine information to the public and health care providers and initiatives targeting minority groups may increase vaccination coverage among this population.

Text4Health: impact of text message reminder-recalls for pediatric and adolescent immunizations

OBJECTIVES

We conducted 2 studies to determine the impact of text message immunization reminder-recalls in an urban, low-income population.

METHODS

In 1 study, text message immunization reminders were sent to a random sample of parents (n = 195) whose children aged 11 to 18 years needed either or both meningococcal (MCV4) and tetanus-diphtheria-acellular pertussis (Tdap) immunizations. We compared receipt of MCV4 or Tdap at 4, 12, and 24 weeks with age- and gender-matched controls. In the other study, we compared attendance at a postshortage Haemophilus influenzae B (Hib) immunization recall session between parents who received text message and paper-mailed reminders (n = 87) and those who only received paper-mailed reminders (n = 87).

RESULTS

Significantly more adolescents with intervention parents received either or both MCV4 and Tdap at weeks 4 (15.4% vs 4.2%; P < .001), 12 (26.7% vs 13.9%; P < .005), and 24 (36.4% vs 18.1%; P < .001). Significantly more parents who received both Hib reminders attended a recall session compared with parents who only received a mailed reminder (21.8% vs 9.2%; P < .05). After controlling for age, gender, race/ethnicity, insurance status, and language, text messaging was still significantly associated with both studies' outcomes.

CONCLUSIONS

Text messaging for reminder-recalls improved immunization coverage in a low-income, urban population.

Correlates of 2009 H1N1 influenza vaccine acceptability among parents and their adolescent children

School-aged children were a priority group for receipt of the pandemic (2009) H1N1 influenza vaccine. Both parental and adolescent attitudes likely influence vaccination behaviors. Data were collected from surveys distributed to middle- and high-school students and their parents in two counties in rural Georgia. Multivariable logistic regression analyses were conducted to assess correlates of parental acceptance of H1N1 influenza vaccination for their children and adolescents' acceptance of vaccination for themselves. Concordance analyses were conducted to assess agreement between parent-adolescent dyads regarding H1N1 influenza vaccine acceptance. Parental acceptance of H1N1 influenza vaccination for their children was associated with acceptance of the vaccine for themselves and feeling motivated by the H1N1 influenza pandemic to get a seasonal influenza vaccine for their child. Adolescents' acceptance was associated with receipt of a seasonal influenza vaccine in the past year, fear of getting H1N1 influenza, feeling comfortable getting the vaccine and parental acceptance of H1N1 influenza vaccine. Half (50%) of parent-adolescent pairs included both a parent and child who expressed H1N1 influenza vaccine acceptance, and 19% of pairs would not accept the vaccine. This research highlights the need for interventions that target factors associated with H1N1 influenza vaccine acceptance among both parents and adolescents.

Factors associated with parental acceptance and refusal of pandemic influenza A/H1N1 vaccine in Turkey

The objective of this study was to investigate the parents' attitudes towards and identify the possible factors associated with pandemic H1N1 vaccine uptake that was recommended to children between 6 months and 5 years of age. A questionnaire exploring the attitudes of parents to H1N1 vaccine was given to parents of children 6 through 60 months of age attending to Akdeniz and Gazi University Hospitals' well-child departments between 15 November 2009 and 15 January 2010. The questionnaire included questions on demographic characteristics, parental perception of the severity of the pandemic, the presence of anyone in their environment who suffered from pandemic influenza, their decision on whether or not to vaccinate their child, the factors that influenced them during decision-making process and possible factors that might have influenced the opponents of their decision. Those who accepted to get their children vaccinated got it immediately, free of charge. Out of 611 parents who responded the questionnaire 226 (36.7%) had their children vaccinated. Parental education period of less than 12 years, not being a close relative of a health care worker, not having a relative who suffered from the disease, having a child younger than 36 months, being influenced by the relatives' opinions or from the politicians or from the media all decreased vaccine acceptance. Factors that were most significantly associated with vaccine refusal were thinking that the pandemic was exaggerated (OR 9.44, 95% CI 4.28-20.82) and believing that other preventive measures were more effective than H1N1 vaccine (OR 15.61, 95% CI 7.37-33.08). Lessons learned from influenza H1N1/2009 pandemic may help national authorities, health care providers and media on how to keep the public well informed and find ways of better risk-benefit communication with the parents on vaccines.