Overview: special focus vaccine acceptance.
01 Aug 2013-Human Vaccines & Immunotherapeutics (Hum Vaccin Immunother)-Vol. 9, Iss: 8, pp 1752-1754
TL;DR: A significant effort will require a significant effort among global health agencies, non-governmental organizations, industry and national governments to support vaccine development and ensure a strong infrastructure for sustainable vaccine delivery.
Abstract: At the World Economic Forum in 2010, The Gates Foundation announced the "Decade of Vaccines," a $10 billion commitment to increase access to existing and new childhood vaccines. It is estimated that this effort could save 6.4 million lives and avert 426 million illnesses [1, 2] Achieving these goals will require a significant effort among global health agencies, non-governmental organizations, industry and national governments to support vaccine development and ensure a strong infrastructure for sustainable vaccine delivery. Vaccines are one of the most important public health achievements in history, resulting in significant decreases in the prevalence of many childhood diseases. However, persistent disparities exist in the adoption of new vaccines and sustained vaccination rates in both developed and developing countries. Decreasing vaccination rates in some communities have resulted in outbreaks of vaccine-preventable diseases. Disparities may be due to vaccine supply, poor infrastructure, or low prioritization of vaccines for public health spending. However, another crucial contributor to the success of vaccination programs is vaccine acceptance.
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TL;DR: Moderate-certainty evidence is found that health education at village meetings or at home probably improves coverage with three doses of diphtheria-tetanus-pertussis vaccines, and that regular immunisation outreach may improve full immunisation coverage.
Abstract: Background
Immunisation is a powerful public health strategy for improving child survival, not only by directly combating key diseases that kill children but also by providing a platform for other health services. However, each year millions of children worldwide, mostly from low- and middle-income countries (LMICs), do not receive the full series of vaccines on their national routine immunisation schedule. This is an update of the Cochrane review published in 2011 and focuses on interventions for improving childhood immunisation coverage in LMICs.
Objectives
To evaluate the effectiveness of intervention strategies to boost and sustain high childhood immunisation coverage in LMICs.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2016, Issue 4, part of The Cochrane Library. www.cochranelibrary.com, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 12 May 2016); MEDLINE In-Process and Other Non-Indexed Citations, MEDLINE Daily and MEDLINE 1946 to Present, OvidSP (searched 12 May 2016); CINAHL 1981 to present, EbscoHost (searched 12 May 2016); Embase 1980 to 2014 Week 34, OvidSP (searched 2 September 2014); LILACS, VHL (searched 2 September 2014); Sociological Abstracts 1952 - current, ProQuest (searched 2 September 2014). We did a citation search for all included studies in Science Citation Index and Social Sciences Citation Index, 1975 to present; Emerging Sources Citation Index 2015 to present, ISI Web of Science (searched 2 July 2016). We also searched the two Trials Registries: ICTRP and ClinicalTrials.gov (searched 5 July 2016)
Selection criteria
Eligible studies were randomised controlled trials (RCT), non-RCTs, controlled before-after studies, and interrupted time series conducted in LMICs involving children aged from birth to four years, caregivers, and healthcare providers.
Data collection and analysis
We independently screened the search output, reviewed full texts of potentially eligible articles, assessed risk of bias, and extracted data in duplicate; resolving discrepancies by consensus. We then conducted random-effects meta-analyses and used GRADE to assess the certainty of evidence.
Main results
Fourteen studies (10 cluster RCTs and four individual RCTs) met our inclusion criteria. These were conducted in Georgia (one study), Ghana (one study), Honduras (one study), India (two studies), Mali (one study), Mexico (one study), Nicaragua (one study), Nepal (one study), Pakistan (four studies), and Zimbabwe (one study). One study had an unclear risk of bias, and 13 had high risk of bias. The interventions evaluated in the studies included community-based health education (three studies), facility-based health education (three studies), household incentives (three studies), regular immunisation outreach sessions (one study), home visits (one study), supportive supervision (one study), information campaigns (one study), and integration of immunisation services with intermittent preventive treatment of malaria (one study).
We found moderate-certainty evidence that health education at village meetings or at home probably improves coverage with three doses of diphtheria-tetanus-pertussis vaccines (DTP3: risk ratio (RR) 1.68, 95% confidence interval (CI) 1.09 to 2.59). We also found low-certainty evidence that facility-based health education plus redesigned vaccination reminder cards may improve DTP3 coverage (RR 1.50, 95% CI 1.21 to 1.87). Household monetary incentives may have little or no effect on full immunisation coverage (RR 1.05, 95% CI 0.90 to 1.23, low-certainty evidence). Regular immunisation outreach may improve full immunisation coverage (RR 3.09, 95% CI 1.69 to 5.67, low-certainty evidence) which may substantially improve if combined with household incentives (RR 6.66, 95% CI 3.93 to 11.28, low-certainty evidence). Home visits to identify non-vaccinated children and refer them to health clinics may improve uptake of three doses of oral polio vaccine (RR 1.22, 95% CI 1.07 to 1.39, low-certainty evidence). There was low-certainty evidence that integration of immunisation with other services may improve DTP3 coverage (RR 1.92, 95% CI 1.42 to 2.59).
Authors' conclusions
Providing parents and other community members with information on immunisation, health education at facilities in combination with redesigned immunisation reminder cards, regular immunisation outreach with and without household incentives, home visits, and integration of immunisation with other services may improve childhood immunisation coverage in LMIC. Most of the evidence was of low certainty, which implies a high likelihood that the true effect of the interventions will be substantially different. There is thus a need for further well-conducted RCTs to assess the effects of interventions for improving childhood immunisation coverage in LMICs.
211 citations
Cites background from "Overview: special focus vaccine acc..."
...Some experts have observed growing concerns about vaccines, which has influenced vaccine acceptance (Bloom 2005; Dubé 2013; Feemster 2013; Larson 2014)....
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...Vaccine acceptance spans a spectrum from complete rejection to total acceptance (Feemster 2013)....
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TL;DR: The results show the heterogeneity of factors influencing vaccine decision making and although the majority of vaccine-hesitant mothers finally chose to follow the recommended vaccine schedule for their child, they were still ambivalent and they continued to question their decision.
Abstract: Parents’ decision to use vaccination services is complex and multi-factorial. Of particular interest are “vaccine-hesitant” parents who are in the middle of the continuum between vaccine acceptance and refusal. The objective of this qualitative longitudinal study was to better understand why mothers choose to vaccinate—or not—their newborns. Fifty-six pregnant mothers living in different areas of Quebec (Canada) were interviewed. These interviews gathered information on mothers’ views about health and vaccination. Almost half of the mothers were categorized as vaccine-hesitant. A second interview was conducted with these mothers 3 to 11 months after birth to look at their actual decision and behavior concerning vaccination. Our results show the heterogeneity of factors influencing vaccine decision making. Although the majority of vaccine-hesitant mothers finally chose to follow the recommended vaccine schedule for their child, they were still ambivalent and they continued to question their decision.
119 citations
Cites background from "Overview: special focus vaccine acc..."
...Vaccine decisions are portrayed as “a spectrum of behaviors and beliefs from rejection of all vaccines to active support of immunization recommendations” (Feemster, 2013, p. 1752)....
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Journal Article•
TL;DR: This review provides an approach for primary care physicians to enable effective communication with parents who have differ-ent levels of concerns about vaccinations and awareness of currently available resources that may be used to support discussions.
Abstract: Background: Vaccine hesitancy is becoming increasingly recognised as an issue in Australia and globally, as concerns about vaccines and their safety predominate over concerns about the risk of vaccine-preventable diseases. Objective: This review provides an approach for primary care physicians to enable effective communication with parents who have different levels of concerns about vaccinations and awareness of currently available resources that may be used to support discussions. Discussion: Clear and flexible communication strategies for healthcare providers to undertake effective discussions with vaccinehesitant parents or clear referral pathways are the key to addressing concerns about vaccination in both primary and secondary care.
34 citations
TL;DR: In this paper, the authors explored parents' and informal caregivers' views and practices regarding routine childhood vaccination, and the factors influencing acceptance, hesitancy, or nonacceptance of childhood vaccination.
Abstract: Background Childhood vaccination is one of the most effective ways to prevent serious illnesses and deaths in children. However, worldwide, many children do not receive all recommended vaccinations, for several potential reasons. Vaccines might be unavailable, or parents may experience difficulties in accessing vaccination services; for instance, because of poor quality health services, distance from a health facility, or lack of money. Some parents may not accept available vaccines and vaccination services. Our understanding of what influences parents' views and practices around childhood vaccination, and why some parents may not accept vaccines for their children, is still limited. This synthesis links to Cochrane Reviews of the effectiveness of interventions to improve coverage or uptake of childhood vaccination. Objectives - Explore parents' and informal caregivers' views and practices regarding routine childhood vaccination, and the factors influencing acceptance, hesitancy, or nonacceptance of routine childhood vaccination. - Develop a conceptual understanding of what and how different factors reduce parental acceptance of routine childhood vaccination. - Explore how the findings of this review can enhance our understanding of the related Cochrane Reviews of intervention effectiveness. Search methods We searched MEDLINE, Embase, CINAHL, and three other databases for eligible studies from 1974 to June 2020. Selection criteria We included studies that: utilised qualitative methods for data collection and analysis; focused on parents' or caregivers' views, practices, acceptance, hesitancy, or refusal of routine vaccination for children aged up to six years; and were from any setting globally where childhood vaccination is provided. Data collection and analysis We used a pre-specified sampling frame to sample from eligible studies, aiming to capture studies that were conceptually rich, relevant to the review's phenomenon of interest, from diverse geographical settings, and from a range of income-level settings. We extracted contextual and methodological data from each sampled study. We used a meta-ethnographic approach to analyse and synthesise the evidence. We assessed methodological limitations using a list of criteria used in previous Cochrane Reviews and originally based on the Critical Appraisal Skills Programme quality assessment tool for qualitative studies. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We integrated the findings of this review with those from relevant Cochrane Reviews of intervention effectiveness. We did this by mapping whether the underlying theories or components of trial interventions included in those reviews related to or targeted the overarching factors influencing parental views and practices regarding routine childhood vaccination identified by this review. Main results We included 145 studies in the review and sampled 27 of these for our analysis. Six studies were conducted in Africa, seven in the Americas, four in South-East Asia, nine in Europe, and one in the Western Pacific. Studies included urban and rural settings, and high-, middle-, and low-income settings. Many complex factors were found to influence parents' vaccination views and practices, which we divided into four themes. Firstly, parents' vaccination ideas and practices may be influenced by their broader ideas and practices surrounding health and illness generally, and specifically with regards to their children, and their perceptions of the role of vaccination within this context. Secondly, many parents' vaccination ideas and practices were influenced by the vaccination ideas and practices of the people they mix with socially. At the same time, shared vaccination ideas and practices helped some parents establish social relationships, which in turn strengthened their views and practices around vaccination. Thirdly, parents' vaccination ideas and practices may be influenced by wider political issues and concerns, and particularly their trust (or distrust) in those associated with vaccination programmes. Finally, parents' vaccination ideas and practices may be influenced by their access to and experiences of vaccination services and their frontline healthcare workers. We developed two concepts for understanding possible pathways to reduced acceptance of childhood vaccination. The first concept, 'neoliberal logic', suggests that many parents, particularly from high-income countries, understood health and healthcare decisions as matters of individual risk, choice, and responsibility. Some parents experienced this understanding as in conflict with vaccination programmes, which emphasise generalised risk and population health. This perceived conflict led some parents to be less accepting of vaccination for their children. The second concept, 'social exclusion', suggests that some parents, particularly from low- and middle-income countries, were less accepting of childhood vaccination due to their experiences of social exclusion. Social exclusion may damage trustful relationships between government and the public, generate feelings of isolation and resentment, and give rise to demotivation in the face of public services that are poor quality and difficult to access. These factors in turn led some parents who were socially excluded to distrust vaccination, to refuse vaccination as a form of resistance or a way to bring about change, or to avoid vaccination due to the time, costs, and distress it creates. Many of the overarching factors our review identified as influencing parents' vaccination views and practices were underrepresented in the interventions tested in the four related Cochrane Reviews of intervention effectiveness. Authors' conclusions Our review has revealed that parents' views and practices regarding childhood vaccination are complex and dynamic social processes that reflect multiple webs of influence, meaning, and logic. We have provided a theorised understanding of the social processes contributing to vaccination acceptance (or not), thereby complementing but also extending more individualistic models of vaccination acceptance. Successful development of interventions to promote acceptance and uptake of childhood vaccination will require an understanding of, and then tailoring to, the specific factors influencing vaccination views and practices of the group(s) in the target setting. The themes and concepts developed through our review could serve as a basis for gaining this understanding, and subsequent development of interventions that are potentially more aligned with the norms, expectations, and concerns of target users.
24 citations
TL;DR: The findings suggest that there exists an opportunity to provide reliable information on vaccination through mobile devices to better inform the public, however predictors of individual engagement with these technologies merits further study.
Abstract: Sub-optimal vaccination coverage and recent outbreaks of vaccine-preventable diseases serve as a reminder that vaccine hesitancy remains a concern. ImmunizeCA, a new smartphone app to help track immunizations, may address several reasons for not vaccinating. We conducted a study to describe demographic variables, attitudes, beliefs and information sources regarding pediatric vaccination in a sample of childbearing women who were willing to download an immunization app. We also sought to measure their current mobile usage behaviors and determine if there is an association between participant demographics, attitudes, beliefs and information sources regarding pediatric vaccination and mobile usage. We recruited participants using a combination of passive and active methods at a tertiary care hospital in Ottawa, Canada. We used surveys to collect demographic information, examine attitudes, behavior, and information sources regarding immunization and self-reported mobile phone usage. A total of 54 women participated. The majority had positive attitudes toward vaccination (96%) and intended to vaccinate their children (98%). Participants were interested in information on pediatric vaccination (94%), and found information from public health the most reliable and accessible (78%). Participants also trusted immunization information from their doctor or nurse and public health (83%) more than other sources. There was variability in participant use of mobile apps for other purposes. The median participant mobile readiness score was 3.2. We found no significant associations between participant age, behavior and attitudes regarding vaccination and mobile readiness scores. This is the first evaluation of mobile readiness for a smartphone app to track immunizations. Our findings suggest that there exists an opportunity to provide reliable information on vaccination through mobile devices to better inform the public, however predictors of individual engagement with these technologies merits further study.
19 citations
References
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TL;DR: This review provides an overview of the phenomenon of vaccine Hesitancy and suggests the possible causes of the apparent increase in vaccine hesitancy in the developed world.
Abstract: Despite being recognized as one of the most successful public health measures, vaccination is perceived as unsafe and unnecessary by a growing number of individuals. Lack of confidence in vaccines is now considered a threat to the success of vaccination programs. Vaccine hesitancy is believed to be responsible for decreasing vaccine coverage and an increasing risk of vaccine-preventable disease outbreaks and epidemics. This review provides an overview of the phenomenon of vaccine hesitancy. First, we will characterize vaccine hesitancy and suggest the possible causes of the apparent increase in vaccine hesitancy in the developed world. Then we will look at determinants of individual decision-making about vaccination.
1,356 citations
TL;DR: The evolution of the vaccine hesitancy movement is described and the individual, vaccine-specific and societal factors contributing to this phenomenon are described.
Abstract: Parental vaccine hesitancy is a growing problem affecting the health of children and the larger population. This article describes the evolution of the vaccine hesitancy movement and the individual, vaccine-specific and societal factors contributing to this phenomenon. In addition, potential strategies to mitigate the rising tide of parent vaccine reluctance and refusal are discussed.
180 citations
TL;DR: Utilizing some of the storytelling strategies used by the anti-vaccine movement, in addition to evidence-based vaccine information, could potentially offer providers, public health officials, and pro- Vaccine parents an opportunity to mount a much stronger defense against anti- vaccines messaging.
Abstract: With little or no evidence-based information to back up claims of vaccine danger, anti-vaccine activists have relied on the power of storytelling to infect an entire generation of parents with fear...
177 citations
TL;DR: This study used the Theory of Planned Behavior to explore associations between sources of vaccine information, parental vaccine concerns, peer norms for vaccine behavior and intentions to follow an alternative immunization schedule and found that number of reported vaccine concerns and concerns about the utility or necessity of vaccines are strongly associated withAlternative immunization intentions.
Abstract: Alternative immunization schedules increase the time a child is unvaccinated and require greater resources from providers. Understanding what drives interest in alternative immunization schedules can potentially inform the design of effective, targeted messages that help to reduce time spent counseling and decrease requests for alternative immunization schedules. This study used the Theory of Planned Behavior to explore associations between sources of vaccine information, parental vaccine concerns, peer norms for vaccine behavior and intentions to follow an alternative immunization schedule. We performed logistic regression using medical record data from a private pediatric practice in a large northeastern city. Routine data were recorded in the EMR by the pediatrician during an initial vaccine counseling conversation with the parent(s). Parents who received vaccine information from doctors were less likely to have immunization concerns while parents who got vaccine information from friends and family or from books were more likely to report specific vaccine concerns. Our multivariate analysis shows that number of reported vaccine concerns and concerns about the utility or necessity of vaccines are strongly associated with alternative immunization intentions. We also find a direct relationship between sources of information about vaccines and alternative immunization intentions. Our results suggest that vaccine concerns and non-physician information sources play an important role in alternative immunization intentions while communication from physicians may play an important role in addressing vaccine concerns and promoting adherence to the ACIP immunization schedule.
117 citations
TL;DR: Greater efforts to communicate the benefits and risks of vaccines and address issues with evidence-based information will help improve and sustain public trust in vaccines and health systems worldwide.
Abstract: Vaccines save millions of lives every year. They are one of the safest and most effective public health interventions in keeping populations healthy while bringing numerous social and economic benefits. Vaccines play an important role in ensuring that children, regardless of where they live, can have a healthy start to life. New financing mechanisms that allow poorer countries to gain access to vaccines faster than ever mean additional deaths and disabilities are projected to be saved during the Decade of Vaccines (2011-2020). Trust in vaccines and in the health system is an important element of public health programs that aim to deliver life-saving vaccines. Indeed, understanding the contributors and threats to trust is essential to explaining vaccine acceptance, particularly as they vary across epidemiologic conditions, specific vaccines and cultural and sociopolitical settings. Greater efforts to communicate the benefits and risks of vaccines and address issues with evidence-based information will help improve and sustain public trust in vaccines and health systems worldwide. Measuring and monitoring trust levels and focusing on deliberate efforts to build trust in vaccines are important steps to reducing vaccine confidence gaps when they occur.
102 citations