Addressing parents' concerns about childhood immunizations: a tutorial for primary care providers

A Select Bibliography of Actions to Promote Vaccine Literacy: A Resource for Health Communication

In this bibliography, the researchers provide an introduction to the available evidence base of actions to promote vaccine literacy. The research team organized interventions to create a tool that can inform health communicators and practitioners seeking a resource focused on strategy and implementation design for actions that support vaccine literacy. This scoping bibliography is honed specifically to respond to the urgency of the current pandemic, when supporting and increasing vaccine literacy offers promise for achieving the critically needed high levels of vaccination. Over the course of the coming months and year, this bibliography will be a dynamic and "living" document hosted and maintained on vaccineliteracy.com.

Perspectives on the Measles, Mumps and Rubella Vaccination among Somali Mothers in Stockholm

Background: Vaccination hesitancy and skepticism among parents hinders progress in achieving full vaccination coverage. Swedish measles, mumps and rubella (MMR) vaccine coverage is high however some areas with low vaccination coverage risk outbreaks. This study aimed to explore factors influencing the decision of Somali parents living in the Rinkeby and Tensta districts of Stockholm, Sweden, on whether or not to vaccinate their children with the measles, mumps and rubella (MMR) vaccine. Method: Participants were 13 mothers of at least one child aged 18 months to 5 years, who were recruited using snowball sampling. In-depth interviews were conducted in Somali and Swedish languages and the data generated was analysed using qualitative content analysis. Both written and verbal informed consent were obtained from participants. Results: Seven of the mothers had not vaccinated their youngest child at the time of the study and decided to postpone the vaccination until their child became older (delayers). The other six mothers had vaccinated their child for MMR at the appointed time (timely vaccinators). The analysis of the data revealed two main themes: (1) barriers to vaccinate on time, included issues surrounding fear of the child not speaking and unpleasant encounters with nurses and (2) facilitating factors to vaccinate on time, included heeding vaccinating parents’ advice, trust in nurses and trust in God. The mothers who had vaccinated their children had a positive impact in influencing other mothers to also vaccinate. Conclusions: Fear, based on the perceived risk that vaccination will lead to autism, among Somali mothers in Tensta and Rinkeby is evident and influenced by the opinions of friends and relatives. Child Healthcare Center nurses are important in the decision-making process regarding acceptance of MMR vaccination. There is a need to address mothers’ concerns regarding vaccine safety while improving the approach of nurses as they address these concerns.

Public subsidies and the recommendation of child vaccines among primary care physicians: a nationwide cross-sectional study in Japan

OBJECTIVE

Although public subsidies and physician recommendations for vaccination play key roles in increasing childhood vaccination coverage, the association between them remains uncertain. This study aimed to identify the association between awareness of public subsidies and recommendations for Haemophilus influenzae type b (Hib), Streptococcus pneumoniae (pneumococcal conjugate vaccine (PCV)) and human papillomavirus (HPV) vaccinations among primary care physicians in Japan.

DESIGN

This is a cross-sectional study.

SETTING

In 2012, a questionnaire was distributed among 3000 randomly selected physicians who were members of the Japan Primary Care Association.

PARTICIPANTS

From the questionnaire, participants were limited to physicians who administered childhood vaccinations.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary measures were participants' awareness of public subsidies and their recommendation levels for Hib, PCV and HPV vaccines. Multiple logistic regression analysis was performed to investigate the association between awareness and recommendation, with adjustment for possible confounders.

RESULTS

The response rate was 25.8% (743/2880). Of 743 physician respondents, 434 were included as analysis subjects. The proportions of those who recommended vaccinations were 57.1% for Hib, 54.1% for PCV and 58.1% for HPV. For each vaccine, multivariable analyses showed physicians who were aware of the subsidy were more likely to recommend vaccination than those who were not aware: the adjusted ORs were 4.21 (95% CI 2.47 to 7.15) for Hib, 4.96 (95% CI 2.89 to 8.53) for PCV and 4.17 (95% CI 2.00 to 8.70) for HPV.

CONCLUSIONS

Primary care physicians' awareness of public subsidies was found to be associated with their recommendations for the Hib, PCV and HPV vaccines. Provision of information about public subsidies to these physicians may increase their likelihood to recommend vaccination.

Pediatric Resident Education and Preparedness Regarding Vaccine-Preventable Diseases

This study assessed pediatric residents' reported knowledge of and self-confidence in identifying/treating 8 vaccine-preventable diseases. Pediatric residents nationwide (n = 385) reported (1) if they had previously diagnosed measles, mumps, rubella, diphtheria, tetanus, pertussis, varicella, and/or polio; (2) their comfort level in treating these diseases; (3) the likelihood of identifying symptoms; and (4) 16 disease-related statements as true/false. More than 25% of residents were not comfortable treating 5 of the 8 diseases. More than 25% reported themselves as unlikely/extremely unlikely to identify symptoms of 3 of these diseases. Third- or fourth-year residents did not feel more confident in identifying disease symptoms than first-year residents, except for pertussis ( P ≤ .01). True/false statement accuracy ranged from 56.8% correct (polio) to 94.6% correct (pertussis). Most residents (73.3%) were "extremely concerned" regarding parental vaccine refusal, and 96.0% felt that they would benefit from receiving more information. Increased emphasis on this subject in residency education is essential for the management of potential disease outbreaks.

"One of the greatest medical success stories:" Physicians and nurses' small stories about vaccine knowledge and anxieties

In recent years, the Canadian province of Alberta experienced outbreaks of measles, mumps, pertussis, and influenza. Even so, the dominant cultural narrative maintains that vaccines are safe, effective, and necessary to maintain population health. Many vaccine supporters have expressed anxieties that stories contradicting this narrative have lowered herd immunity levels because they frighten the public into avoiding vaccination. As such, vaccine policies often emphasize educating parents and the public about the importance and safety of vaccination. These policies rely on health professionals to encourage vaccine uptake and assume that all professionals support vaccination. Health professionals, however, are socially positioned between vaccine experts (such as immunologists) and non-experts (the wider public). In this article, I discuss health professionals' anxieties about the potential risks associated with vaccination and with the limitations of Alberta's immunisation program. Specifically, I address the question: If medical knowledge overwhelmingly supports vaccination, then why do some professionals continue to question certain vaccines? To investigate this topic, I interviewed twenty-seven physicians and seven nurses. With stock images and small stories that interviewees shared about their vaccine anxieties, I challenge the common assumption that all health professionals support vaccines uncritically. All interviewees provided generic statements that supported vaccination and Alberta's immunisation program, but they expressed anxieties when I asked for details. I found that their anxieties reflected nuances that the culturally dominant vaccine narrative overlooks. Particularly, they critiqued the influence that pharmaceutical companies, the perceived newness of specific vaccines, and the limitations of medical knowledge and vaccine schedules.

Immunization Rejection in Southern Alberta: A Comparison of the Perspectives of Mothers and Health Professionals

Qualitative grounded theory was used to compare and contrast the understanding and decision-making process of non-immunizing mothers and health professionals' perceptions of these mothers' understanding and decision-making process. The sample comprised 8 mothers with purposefully unimmunized children under the age of 6 years and 12 health professionals. Semi-structured interviews were conducted and the data generated were analyzed using data immersion, memo-writing, and 3 stages of coding. The mothers and health professionals identified similar, interrelated factors influencing the mothers' decision, categorized into 4 groups: emotions, beliefs, facts, and information. Three primary themes were evident: the health professionals emphasized the influence of religion in decision-making to a greater extent than did the mothers, the meaning of evidence appeared to differ for mothers and health professionals, and mothers revealed a mistrust of health professionals. Immunization is a public health issue; collaboration and understanding are necessary to promote positive health outcomes in children.

"Everybody just wants to do what's best for their child": Understanding how pro-vaccine parents can support a culture of vaccine hesitancy

BACKGROUND

Although a large majority of parents vaccinate their children, vaccine hesitancy has become more widespread. It is not well understood how this culture of vaccine hesitancy has emerged and how it influences parents' decisions about vaccine schedules.

OBJECTIVE

We sought to examine how attitudes and beliefs of parents who self-report as pro-vaccine are developed and contribute to immunization decisions, including delaying or spacing vaccines.

METHODS

Open-ended, in-depth interviews (N=23) were conducted with upper-middle class parents with young children living in Philadelphia. Interview data were coded and key themes identified related to vaccine decision-making.

RESULTS

Parents who sought out vaccine information were often overwhelmed by the quantity and ambiguity when interpreting that information, and, consequently, had to rely on their own instinct or judgment to make vaccine decisions. In particular, while parents in this sample did not refuse vaccines, and described themselves as pro-vaccine, they did frequently delay or space vaccines. This experience also generated sympathy for and tolerance of vaccine hesitancy in other parents. Parents also perceived minimal severe consequences for deviating from the recommended immunization schedule.

CONCLUSION

These findings suggest that the rise in and persistence of vaccine hesitancy and refusal are, in part, influenced by the conflicts in the information parents gather, making it difficult to interpret. Considerable deviations from the recommended vaccination schedule may manifest even within a pro-vaccine population due to this perceived ambiguity of available information and resulting tolerance for vaccine hesitancy.

Strategies for addressing vaccine hesitancy - A systematic review

The purpose of this systematic review is to identify, describe and assess the potential effectiveness of strategies to respond to issues of vaccine hesitancy that have been implemented and evaluated across diverse global contexts.

METHODS

A systematic review of peer reviewed (January 2007-October 2013) and grey literature (up to October 2013) was conducted using a broad search strategy, built to capture multiple dimensions of public trust, confidence and hesitancy concerning vaccines. This search strategy was applied and adapted across several databases and organizational websites. Descriptive analyses were undertaken for 166 (peer reviewed) and 15 (grey literature) evaluation studies. In addition, the quality of evidence relating to a series of PICO (population, intervention, comparison/control, outcomes) questions defined by the SAGE Working Group on Vaccine Hesitancy (WG) was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria; data were analyzed using Review Manager.

RESULTS

Across the literature, few strategies to address vaccine hesitancy were found to have been evaluated for impact on either vaccination uptake and/or changes in knowledge, awareness or attitude (only 14% of peer reviewed and 25% of grey literature). The majority of evaluation studies were based in the Americas and primarily focused on influenza, human papillomavirus (HPV) and childhood vaccines. In low- and middle-income regions, the focus was on diphtheria, tetanus and pertussis, and polio. Across all regions, most interventions were multi-component and the majority of strategies focused on raising knowledge and awareness. Thirteen relevant studies were used for the GRADE assessment that indicated evidence of moderate quality for the use of social mobilization, mass media, communication tool-based training for health-care workers, non-financial incentives and reminder/recall-based interventions. Overall, our results showed that multicomponent and dialogue-based interventions were most effective. However, given the complexity of vaccine hesitancy and the limited evidence available on how it can be addressed, identified strategies should be carefully tailored according to the target population, their reasons for hesitancy, and the specific context.

Compliance with regimens of existing vaccines in Orumba North local government area of Anambra state, Nigeria

The factors associated with third dose of diphtheria, pertussis and tetanus (DPT3) uptake, a true indicator of compliance with required regimen of vaccines, in Anambra state, Nigeria, were investigated in a cross-sectional survey of 600 mothers (15-49). Being an older mother showed a positive association with compliance. Compliance was more among those who used the government health facilities for their health needs (χ(2 )= 12.286, p < .001). Satisfactory experiences with health service influenced compliance (χ(2 )= 8.542, p = .002). Those with good perception (30.1%) complied more (χ(2 )= 42.572, p < .001). Those who were aware that immunization protects the children against vaccine preventable diseases complied more (χ(2 )= 8.735, p = .002). In conclusion, the action-hesitancy model strengthens the Health Belief Model in explaining parents' attitude to childhood immunization, as experience and perception of the health service influenced uptake more. Health education and campaigns should be directed at factors that would encourage mothers to adopt required behaviours.

Compliance With Regimens of Existing Vaccines in Orumba North Local Government Area of Anambra State, Nigeria

The factors associated with third dose of diphtheria, pertussis and tetanus (DPT3) uptake, a true indicator of compliance with required regimen of vaccines, in Anambra state, Nigeria, were investigated in a cross-sectional survey of 600 mothers (15–49). Being an older mother showed a positive association with compliance. Compliance was more among those who used the government health facilities for their health needs (χ2 = 12.286, p < .001). Satisfactory experiences with health service influenced compliance (χ2 = 8.542, p = .002). Those with good perception (30.1%) complied more (χ2 = 42.572, p < .001). Those who were aware that immunization protects the children against vaccine preventable diseases complied more (χ2 = 8.735, p = .002). In conclusion, the action-hesitancy model strengthens the Health Belief Model in explaining parents’ attitude to childhood immunization, as experience and perception of the health service influenced uptake more. Health education and campaigns should be directed at factors that would encourage mothers to adopt required behaviours.

Are healthcare workers' intentions to vaccinate related to their knowledge, beliefs and attitudes? A systematic review

BACKGROUND

The Summit of Independent European Vaccination Experts (SIEVE) recommended in 2007 that efforts be made to improve healthcare workers' knowledge and beliefs about vaccines, and their attitudes towards them, to increase vaccination coverage. The aim of the study was to compile and analyze the areas of disagreement in the existing evidence about the relationship between healthcare workers' knowledge, beliefs and attitudes about vaccines and their intentions to vaccinate the populations they serve.

METHODS

We conducted a systematic search in four electronic databases for studies published in any of seven different languages between February 1998 and June 2009. We included studies conducted in developed countries that used statistical methods to relate or associate the variables included in our research question. Two independent reviewers verified that the studies met the inclusion criteria, assessed the quality of the studies and extracted their relevant characteristics. The data were descriptively analyzed.

RESULTS

Of the 2354 references identified in the initial search, 15 studies met the inclusion criteria. The diversity in the study designs and in the methods used to measure the variables made it impossible to integrate the results, and each study had to be assessed individually. All the studies found an association in the direction postulated by the SIEVE experts: among healthcare workers, higher awareness, beliefs that are more aligned with scientific evidence and more favorable attitudes toward vaccination were associated with greater intentions to vaccinate. All the studies included were cross-sectional; thus, no causal relationship between the variables was established.

CONCLUSION

The results suggest that interventions aimed at improving healthcare workers' knowledge, beliefs and attitudes about vaccines should be encouraged, and their impact on vaccination coverage should be assessed.

Parent-reported reasons for nonreceipt of recommended adolescent vaccinations, national immunization survey: teen, 2009

OBJECTIVES

To identify parent-reported reasons for non-receipt of adolescent vaccinations by provider recommendation status.

METHODS

Parental reasons for non-receipt of adolescent vaccines were analyzed among adolescents 13-17 years using data from the 2009 National Immunization Survey-Teen (n=20,066).

RESULTS

Among unvaccinated adolescents, 87.9% (Td/Tdap), 90.9% (MenACWY), and 66.0% (HPV) of parents reported that they did not receive a healthcare provider recommendation for their adolescent to receive the vaccine. Among those without a provider recommendation, the most common reasons for not receiving the vaccines were 'vaccine not recommended' [Td/Tdap, MenACWY] and 'not needed' [HPV]. Among those with a recommendation, the most common parental reasons were 'lack of knowledge' [Td/Tdap], 'vaccine not needed' [MenACWY], and 'lack of knowledge' [HPV].

CONCLUSIONS

Non-receipt of provider recommendations was a main parent-reported reason for not getting vaccinated. Increasing parental knowledge and vaccination coverage through increased provider-parent communication about disease risk and vaccine benefits is needed.

Pediatricians' experience with and response to parental vaccine safety concerns and vaccine refusals: a survey of Connecticut pediatricians

OBJECTIVES

Physicians are seeing increasing numbers of parents who question the safety of vaccines or refuse to vaccinate their children. This study examined how frequently pediatricians in one New England state encounter parental vaccine safety concerns and vaccine refusals, how often physicians dismiss families from their practices for vaccine refusal, and how parental vaccine refusal impacts pediatricians personally.

METHODS

The study consisted of a quantitative survey of primary care pediatricians in one New England state; 133 pediatricians completed the questionnaire. Variables examined included number of parental vaccine concerns and refusals seen by each physician, physicians' response to parental vaccine concerns and refusals, the personal impact of parental vaccine safety refusals on pediatricians, and respondent estimates of socioeconomic characteristics of families seen in their practices.

RESULTS

The majority of responding pediatricians reported an increase in parental vaccine safety concerns and refusals. More than 30% of responding pediatricians have dismissed families because of their refusal to immunize. Suburban physicians caring for wealthier, better educated families experience more vaccine concerns and/or refusals and are more likely to dismiss families for vaccine refusal. Vaccine refusals have a negative personal impact on one-third of physician respondents.

CONCLUSIONS

Pediatricians in Connecticut are reporting increased levels of parental vaccine safety concerns and refusals. Physicians who report more parental vaccine safety concerns and refusals and who care for wealthier, better educated families are more likely to dismiss families who refuse vaccines and to be negatively affected by parental vaccine refusals, which may adversely impact childhood vaccination rates.

An evaluation of pediatric residency education in conveying immunization knowledge

BACKGROUND

The Accreditation Council of Graduate Medical Education now requires all pediatric residency training programs assess medical knowledge competency.

PURPOSE

The goal of this project was to determine whether pediatric residency training using patient-based/experiential teaching made residents competent in the area of immunization knowledge or whether additional teaching strategies might need to be developed.

METHODS

Cross-sectional and longitudinal study designs were used to determine improvement in immunization knowledge on a multiple-choice quiz over the 3 years of residency training.

RESULTS

Both the cross-sectional and longitudinal data showed a statistically significant improvement in performance between residency training Years 1 and 2 but not between Years 2 and 3 on the quiz. This statistically significant relationship by year of training was seen despite the modest reliability of the short quiz and the sample size.

CONCLUSIONS

This study shows that pediatric residency education using patient-based/experiential teaching is effective in teaching first year residents about immunization knowledge but is not as effective for 2nd- and 3rd-year residents. Other instructional methods such as computer-based cases could be employed during the 2nd and 3rd years.

Parents with doubts about vaccines: which vaccines and reasons why

OBJECTIVES

The goals were (1) to obtain national estimates of the proportions of parents with indicators of vaccine doubt, (2) to identify factors associated with those parents, compared with parents reporting no vaccine doubt indicators, (3) to identify the specific vaccines that prompted doubt and the reasons why, and (4) to describe the main reasons parents changed their minds about delaying or refusing a vaccine for their child.

METHODS

Data were from the National Immunization Survey (2003-2004). Groups included parents who ever got a vaccination for their child although they were not sure it was the best thing to do ("unsure"), delayed a vaccination for their child ("delayed"), or decided not to have their child get a vaccination ("refused").

RESULTS

A total of 3924 interviews were completed. Response rates were 57.9% in 2003 and 65.0% in 2004. Twenty-eight percent of parents responded yes to ever experiencing >or=1 of the outcome measures listed above. In separate analyses for each outcome measure, vaccine safety concern was a predictor for unsure, refused, and delayed parents. The largest proportions of unsure and refused parents chose varicella vaccine as the vaccine prompting their concern, whereas delayed parents most often reported "not a specific vaccine" as the vaccine prompting their concern. Most parents who delayed vaccines for their child did so for reasons related to their child's illness, unlike the unsure and refused parents. The largest proportion of parents who changed their minds about delaying or not getting a vaccination for their child listed "information or assurances from health care provider" as the main reason.

CONCLUSIONS

Parents who exhibit doubts about immunizations are not all the same. This research suggests encouraging children's health care providers to solicit questions about vaccines, to establish a trusting relationship, and to provide appropriate educational materials to parents.