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Marshall S, Fleming A, Sahm LJ, Moore AC. Identifying intervention strategies to improve HPV vaccine decision-making using behaviour change theory. Vaccine 2023; 41:1368-1377. [PMID: 36669967 DOI: 10.1016/j.vaccine.2023.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 01/25/2022] [Accepted: 01/11/2023] [Indexed: 01/20/2023]
Abstract
Although the HPV vaccine is highly safe and effective, its uptake is sub-optimal in many countries, including Ireland. There is therefore a need to identify appropriate interventions that will increase HPV vaccine acceptance by parents. In this study, we took a systematic approach to understand the factors that influence HPV vaccine uptake by parents of adolescent girls in Ireland to define suitable behaviour change interventions that would support positive vaccine decision-making in the future. Specifically, we conducted semi-structured interviews, used a Theoretical Domains Framework (TDF)-based topic guide, to gain insight into the knowledge, beliefs, attitudes and current behaviours of parents with respect to their HPV vaccine decision. Transcripts were analysed using the TDF. The Behaviour Change Wheel (BCW) was used to identify relevant intervention functions and the Behaviour Change Technique Taxonomy version 1 (BCTTv1), to identify relevant intervention techniques. All parents discussed the essential role of healthcare providers in vaccine decision-making. Complacency and confidence were important factors in decision-making by vaccine hesitant parents. Five BCW intervention functions were identified as appropriate, namely; education; persuasion; environmental restructuring; modelling and enablement. To our knowledge, this is the first study to systematically evaluate HPV vaccine decision-making using behaviour change theory and identify suitable intervention strategies to promote positive vaccine decision-making using this approach.
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Affiliation(s)
- Sarah Marshall
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland.
| | - Aoife Fleming
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland; Department of Pharmacy, Mercy University Hospital, Cork, Ireland
| | - Laura J Sahm
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland; Department of Pharmacy, Mercy University Hospital, Cork, Ireland
| | - Anne C Moore
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland; School of Biochemistry and Cell Biology, University College Cork, Cork, Ireland
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Marshall S, Moore AC, Fleming A, Sahm LJ. A Video-Based Behavioral Intervention Associated with Improved HPV Knowledge and Intention to Vaccinate. Vaccines (Basel) 2022; 10:vaccines10040562. [PMID: 35455311 PMCID: PMC9025539 DOI: 10.3390/vaccines10040562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/11/2022] [Accepted: 04/02/2022] [Indexed: 02/04/2023] Open
Abstract
The aim of this study was to design, develop, and evaluate the feasibility of a theory- and evidence-based intervention to improve human papillomavirus (HPV) and HPV vaccine knowledge and intention to vaccinate, among parent–daughter dyads. A theory- and evidence-based online behavioral intervention, “Is the HPV vaccine for me?”, was developed to improve HPV and HPV vaccine knowledge and intention to vaccinate. Knowledge, intention to vaccinate, and feasibility of the intervention were evaluated in a prospective, randomized, controlled feasibility trial. A total of 49 parent–daughter dyads completed the baseline knowledge assessment (n = 24 control, n = 25 intervention), and 35 dyads completed the knowledge assessment at week 2 (n = 17 control, n = 18 intervention). The intervention resulted in a statistically significant increase in HPV and HPV vaccine knowledge and intention to vaccinate. All intervention participants found the video interesting, while 96% found it useful. This intervention was found to be useful, effective, safe, and acceptable in this feasibility study.
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Affiliation(s)
- Sarah Marshall
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, T12 K8AF Cork, Ireland; (S.M.); (A.F.)
| | - Anne C. Moore
- School of Biochemistry and Cell Biology, University College Cork, T12 K8AF Cork, Ireland;
| | - Aoife Fleming
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, T12 K8AF Cork, Ireland; (S.M.); (A.F.)
- Department of Pharmacy, Mercy University Hospital, T12 WE28 Cork, Ireland
| | - Laura J. Sahm
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, T12 K8AF Cork, Ireland; (S.M.); (A.F.)
- Department of Pharmacy, Mercy University Hospital, T12 WE28 Cork, Ireland
- Correspondence:
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Mitchell H, Lim R, Gill PK, Dhanoa J, Dubé È, Bettinger JA. What do adolescents think about vaccines? Systematic review of qualitative studies. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0001109. [PMID: 36962668 PMCID: PMC10022047 DOI: 10.1371/journal.pgph.0001109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 09/02/2022] [Indexed: 11/19/2022]
Abstract
Adolescence presents a key opportunity to build vaccine-related health literacy and promote vaccine confidence and uptake. Although adolescents are central to vaccination programs, their views around vaccines are frequently underrepresented in qualitative literature. We reviewed qualitative studies to systematically identify and summarize existing evidence on adolescents' own understanding of vaccines and experiences with vaccine decision-making, including self-consent when applicable. CINAHL; Embase; Ovid Medline; and Psych Info database searches were last updated on May 28, 2022. Data pertaining to general study characteristics, participant demographics, and qualitative content were extracted independently by two reviewers and analyzed using textual narrative synthesis. Out of 3559 individual records, 59 studies were included. The majority of the studies were conducted in high-income countries and 75% focused on human papilloma virus vaccines, with the remaining studies looking at COVID-19, meningococcal, hepatitis B and influenza vaccines or adolescent experiences with vaccines in general. Adolescent self-consent was explored in 7 studies. Perspectives from sexual and gender minorities were lacking across studies. Adolescents often had limited understanding of different vaccines and commonly perceived vaccine information to be directed towards their parents rather than themselves. Many adolescents felt school-based vaccine education and information available through healthcare providers were insufficient to make informed decisions about vaccines. While adolescents described obtaining vaccine information from traditional and online media, face-to-face interactions and opinions from trusted adults remained important. Adolescents generally relied on their parents for vaccine-decision making, even when self-consent was an option. A notable exception to this included marginalized adolescents who could not rely on parents for health-related advice. Qualitative literature about adolescent vaccines would be enriched by studies examining vaccines other than the HPV vaccine, studies examining adolescent vaccine programs in low and middle-income countries, and by deliberately eliciting vaccine experiences of adolescent with diverse sexual orientation and gender identities.
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Affiliation(s)
- Hana Mitchell
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Rebecca Lim
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Prubjot K Gill
- University of British Columbia Library, University of British Columbia, Vancouver, BC, Canada
| | - Joban Dhanoa
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Ève Dubé
- Institut National de Santé Publique du Québec, Québec City, Canada
| | - Julie A Bettinger
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
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Olagoke A, Caskey R, Floyd B, Hebert-Beirne J, Boyd A, Molina Y. The interdependent roles of the psychosocial predictors of human papillomavirus vaccination among Christian parents of unvaccinated adolescents. Hum Vaccin Immunother 2021; 17:5433-5438. [PMID: 34856881 DOI: 10.1080/21645515.2021.2006027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Despite the availability of the human papillomavirus (HPV) vaccine, uptake has been sub-optimal among certain religious groups. Psychosocial factors (threat appraisal, coping appraisal, and attitudes) have been identified as independent determinants of HPV vaccination. However, their interdependent effects have not been tested. We examined the interdependency of these psychosocial factors in predicting HPV vaccination intention among Christian parents of unvaccinated adolescents (using a theory-driven conceptual model). A cross-sectional study of 342 participants showed that perceived self-efficacy (β = 0.2, 0.11-0.29, p = <0.0001) and perceived response efficacy of HPV vaccine (β = 0.65, 0.53-0.77. p < .0001) were positively associated with vaccination intention. Our mediation analysis (using the Preachers and Hayes' approach) shows that attitudes toward HPV vaccination mediated 59% of the relationship between perceived self-efficacy to vaccinate child and HPV vaccination intention; and 61% of the relationship between perceived response efficacy of HPV vaccine and HPV vaccination intention. Attitudes may be the psychosocial factor that drives the effects of coping appraisal. Therefore, designing an attitude-based intervention to address religious barrier beliefs among Christian parents may nullify the impact of low self-efficacy and response efficacy on HPV vaccination.
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Affiliation(s)
- Ayokunle Olagoke
- Division of Community Health Sciences, School of Public Health, University of Illinois, Chicago, IL, USA
| | - Rachel Caskey
- Division of Community Health Sciences, School of Public Health, University of Illinois, Chicago, IL, USA.,Sections of General Internal Medicine and Pediatrics, University of Illinois, Chicago, IL, USA.,Chicago Cancer Center, University of Illinois, Chicago, IL, USA
| | - Brenikki Floyd
- Division of Community Health Sciences, School of Public Health, University of Illinois, Chicago, IL, USA
| | - Jennifer Hebert-Beirne
- Division of Community Health Sciences, School of Public Health, University of Illinois, Chicago, IL, USA
| | - Andrew Boyd
- Department of Biomedical and Health Information Science, University of Illinois, Chicago, IL, USA
| | - Yamilé Molina
- Division of Community Health Sciences, School of Public Health, University of Illinois, Chicago, IL, USA.,Chicago Cancer Center, University of Illinois, Chicago, IL, USA.,College of Medicine, Center for Research on Women and Gender, University of Illinois, Chicago, IL, USA
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Liew TM, Lee CS. Examining the Utility of Social Media in COVID-19 Vaccination: Unsupervised Learning of 672,133 Twitter Posts. JMIR Public Health Surveill 2021; 7:e29789. [PMID: 34583316 PMCID: PMC8568045 DOI: 10.2196/29789] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/01/2021] [Accepted: 09/18/2021] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Although COVID-19 vaccines have recently become available, efforts in global mass vaccination can be hampered by the widespread issue of vaccine hesitancy. OBJECTIVE The aim of this study was to use social media data to capture close-to-real-time public perspectives and sentiments regarding COVID-19 vaccines, with the intention to understand the key issues that have captured public attention, as well as the barriers and facilitators to successful COVID-19 vaccination. METHODS Twitter was searched for tweets related to "COVID-19" and "vaccine" over an 11-week period after November 18, 2020, following a press release regarding the first effective vaccine. An unsupervised machine learning approach (ie, structural topic modeling) was used to identify topics from tweets, with each topic further grouped into themes using manually conducted thematic analysis as well as guided by the theoretical framework of the COM-B (capability, opportunity, and motivation components of behavior) model. Sentiment analysis of the tweets was also performed using the rule-based machine learning model VADER (Valence Aware Dictionary and Sentiment Reasoner). RESULTS Tweets related to COVID-19 vaccines were posted by individuals around the world (N=672,133). Six overarching themes were identified: (1) emotional reactions related to COVID-19 vaccines (19.3%), (2) public concerns related to COVID-19 vaccines (19.6%), (3) discussions about news items related to COVID-19 vaccines (13.3%), (4) public health communications about COVID-19 vaccines (10.3%), (5) discussions about approaches to COVID-19 vaccination drives (17.1%), and (6) discussions about the distribution of COVID-19 vaccines (20.3%). Tweets with negative sentiments largely fell within the themes of emotional reactions and public concerns related to COVID-19 vaccines. Tweets related to facilitators of vaccination showed temporal variations over time, while tweets related to barriers remained largely constant throughout the study period. CONCLUSIONS The findings from this study may facilitate the formulation of comprehensive strategies to improve COVID-19 vaccine uptake; they highlight the key processes that require attention in the planning of COVID-19 vaccination and provide feedback on evolving barriers and facilitators in ongoing vaccination drives to allow for further policy tweaks. The findings also illustrate three key roles of social media in COVID-19 vaccination, as follows: surveillance and monitoring, a communication platform, and evaluation of government responses.
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Affiliation(s)
- Tau Ming Liew
- Department of Psychiatry, Singapore General Hospital, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Cia Sin Lee
- SingHealth Polyclinics, Singapore, Singapore
- Family Medicine Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
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Davies C, Marshall HS, Zimet G, McCaffery K, Brotherton JML, Kang M, Garland S, Kaldor J, McGeechan K, Skinner SR. Effect of a School-Based Educational Intervention About the Human Papillomavirus Vaccine on Psychosocial Outcomes Among Adolescents: Analysis of Secondary Outcomes of a Cluster Randomized Trial. JAMA Netw Open 2021; 4:e2129057. [PMID: 34726749 PMCID: PMC8564580 DOI: 10.1001/jamanetworkopen.2021.29057] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Delivery of vaccination to adolescents via a school-based program provides an opportunity to promote their involvement in health decision-making, service provision, and self-efficacy (belief in one's ability to perform a certain behavior). OBJECTIVE To examine the effect of a human papillomavirus (HPV) vaccination education and logistical intervention on adolescent psychosocial outcomes. DESIGN, SETTING, AND PARTICIPANTS In this cluster randomized trial and process and qualitative evaluation, adolescents aged 12 to 13 years (first year of high school) were recruited at high schools in Western Australia (WA) and South Australia (SA) in 2013 and 2014. Statistical analysis was performed from January 2016 to December 2020. INTERVENTIONS The complex intervention consisted of an adolescent intervention to promote knowledge and psychosocial outcomes, shared decisional support tool, and logistical strategies. MAIN OUTCOMES AND MEASURES Prespecified secondary outcomes were assessed. The HPV Adolescent Vaccination Intervention Questionnaire (HAVIQ) was used to measure changes in adolescent knowledge (6-item subscale), fear and anxiety (6-item subscale), self-efficacy (5-item subscale), and decision-making (8-item subscale). The hypothesis was that the intervention would improve adolescent involvement in vaccine decision-making (measured before dose 1 only), improve vaccine-related self-efficacy, and reduce vaccine-related fear and anxiety (measured before doses 1, 2, and 3). Mean (SD) scores for each subscale were compared between intervention and control students. In the process evaluation, focus groups were conducted. Analyses of the HAVIQ data were conducted from 2016 to 2020. Qualitative analyses of the focus groups were undertaken from 2017 to 2020. RESULTS The trial included 40 schools (21 intervention and 19 control) across sectors with 6967 adolescents (mean [SD] age, 13.70 [0.45] years). There were 3805 students (1689 girls and 2116 boys) in the intervention group and 3162 students (1471 girls and 1691 boys) in the control group. The overall response rate for the HAVIQ was 55%. In WA, where parental consent was required, the response rate was 35% (1676 of 4751 students); in SA, where parental consent was not required, it was 97% (2166 of 2216 students). The mean (SD) score for decision-making in the intervention group before dose 1 was 3.50 (0.42) of 5 points and 3.40 (0.40) in the control group, a small but significant difference of 0.11 point (95% CI, 0.06 to 0.16 point; P < .001). There was a small difference in favor of the intervention group in reduced vaccination-related anxiety (pre-dose 1 difference, -0.11 point [95% CI, -0.19 to -0.02 point]; pre-dose 2 difference, -0.18 point [95% CI, -0.26 to -0.10 point]; pre-dose 3 difference, -0.18 [95% CI, -0.24 to -0.11]) and increased vaccination self-efficacy (pre-dose 1 difference, 4.0 points; [95% CI, 1.0 to 7.0 points]; pre-dose 2 difference, 4.0 points [95% CI, 2.0 to 6.0 points]; pre-dose 3 difference, 3.0 points [95% CI, 1.0 to 5.0 points]). Focus group data from 111 adolescents in 6 intervention and 5 control schools revealed more confidence and less anxiety with each vaccine dose. CONCLUSIONS AND RELEVANCE In this cluster randomized trial, there was a small difference in adolescent decisional involvement and vaccine-related confidence and reduced vaccination-related fear and anxiety that was maintained throughout the vaccine course in the intervention vs control groups. Guidelines for vaccination at school should incorporate advice regarding how this outcome can be achieved. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry: ACTRN12614000404628.
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Affiliation(s)
- Cristyn Davies
- Specialty of Child and Adolescent Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Helen S. Marshall
- Women’s and Children’s Hospital and School of Medicine and Robinson Research Institute, The University of Adelaide, South Australia, Australia
| | - Gregory Zimet
- Department of Pediatrics, Division of Adolescent Medicine, Indiana University School of Medicine, Indianapolis
| | - Kirsten McCaffery
- Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Julia M. L. Brotherton
- VCS Population Health, VCS Foundation, Victoria, Australia
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Melissa Kang
- Specialty of General Practice, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Health, School of Public Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Suzanne Garland
- Centre for Women’s Infectious Diseases Research, The Royal Women’s Hospital, Melbourne, Victoria, Australia
- Reproductive and Neonatal Infectious Diseases, Department of Obstetrics and Gynaecology, University of Melbourne, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - John Kaldor
- The Kirby Institute for Infection and Immunity in Society, Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Kevin McGeechan
- Faculty of Medicine and Health, The University of Sydney School of Public Health, Sydney, New South Wales, Australia
| | - S. Rachel Skinner
- Specialty of Child and Adolescent Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Cadeddu C, Castagna C, Sapienza M, Lanza TE, Messina R, Chiavarini M, Ricciardi W, de Waure C. Understanding the determinants of vaccine hesitancy and vaccine confidence among adolescents: a systematic review. Hum Vaccin Immunother 2021; 17:4470-4486. [PMID: 34473589 DOI: 10.1080/21645515.2021.1961466] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Vaccine hesitancy (VH) in the age of adolescence is a major public health issue, though it has not been widely examined in the scientific literature. This systematic review aims to address the determinants of VH among adolescents aged 10-19. PubMed, Scopus, and Web of Science were searched from the inception until 11 December 2020. Articles in English, assessing adolescents' attitudes toward vaccination in terms of hesitancy and/or confidence were considered eligible. Out of 14,704 articles, 20 studies were included in the qualitative analysis. Quality assessment was performed through the Appraisal tool for Cross-Sectional Studies (AXIS). A better knowledge of vaccine-preventable diseases, a higher confidence in vaccines, as well as an active involvement in the decision-making process showed a positive relationship with adolescents' vaccine uptake. These aspects should be considered to plan tailored interventions for the promotion of vaccination among adolescents and to reduce VH. Major limitations of this review are represented by the high heterogeneity of the tools used in the primary studies and the lack of standardization in outcomes definitions. Future research is needed to disentangle the interrelationship among the different determinants of VH in this age group.
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Affiliation(s)
- Chiara Cadeddu
- Section of Hygiene, University Department of Life Sciences and Public Health, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Carolina Castagna
- Section of Hygiene, University Department of Life Sciences and Public Health, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Martina Sapienza
- Section of Hygiene, University Department of Life Sciences and Public Health, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Teresa Eleonora Lanza
- Section of Hygiene, University Department of Life Sciences and Public Health, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Rosaria Messina
- Section of Hygiene, University Department of Life Sciences and Public Health, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Manuela Chiavarini
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Walter Ricciardi
- Section of Hygiene, University Department of Life Sciences and Public Health, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Chiara de Waure
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
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Understanding How Adolescents Think about the HPV Vaccine. Vaccines (Basel) 2020; 8:vaccines8040693. [PMID: 33218156 PMCID: PMC7711578 DOI: 10.3390/vaccines8040693] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/10/2020] [Accepted: 11/13/2020] [Indexed: 01/07/2023] Open
Abstract
Despite educational efforts, Tennessee human papillomavirus (HPV) vaccination rates are 43%, among the lowest in the United States. This study examined how adolescents think about the HPV vaccine to identify patterns and misconceptions to enhance educational efforts. Adolescents (ages 11–12) (N = 168) responded to open-ended questions regarding their thinking about the HPV vaccine. Data were analyzed and interpreted using qualitative thematic analysis. Three domains of themes emerged from responses: (1) characteristics of HPV vaccination, (2) knowledge-related themes, and (3) beliefs-related themes. Prevention of HPV and cancer was the most referenced characteristic of HPV vaccination followed by HPV vaccine rates and HPV vaccine efficacy. Student inquiries were mostly centered on HPV vaccine composition, administration, duration and how the vaccine interacts with the body. Some responses indicated a desire for more information about HPV not specific to the HPV vaccine. Overall, adolescent attitudes were positive towards the HPV vaccine. This study highlights specific questions adolescents have about the vaccine that can be used to tailor future HPV educational efforts, empowering adolescents with the knowledge to be more active students in the decision-making process. In addition, the potential for adolescents to serve as community advocates for the vaccine should be considered for future interventions.
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All Good Things. Public Health 2019. [DOI: 10.1016/j.puhe.2019.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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