1
|
Shuldiner J, Green ME, Kiran T, Khan S, Frymire E, Moineddin R, Kerr M, Tadrous M, Nowak DA, Kwong JC, Hu J, Witteman HO, Hamilton B, Bogoch I, Marshall LJ, Ikura S, Bar-Ziv S, Kaplan D, Ivers N. Characteristics of primary care practices by proportion of patients unvaccinated against SARS-CoV-2: a cross-sectional cohort study. CMAJ 2024; 196:E432-E440. [PMID: 38589026 PMCID: PMC11001391 DOI: 10.1503/cmaj.230816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Variations in primary care practices may explain some differences in health outcomes during the COVID-19 pandemic. We sought to evaluate the characteristics of primary care practices by the proportion of patients unvaccinated against SARS-CoV-2. METHODS We conducted a population-based, cross-sectional cohort study using linked administrative data sets in Ontario, Canada. We calculated the percentage of patients unvaccinated against SARS-CoV-2 enrolled with each comprehensive-care family physician, ranked physicians according to the proportion of patients unvaccinated, and identified physicians in the top 10% (v. the other 90%). We compared characteristics of family physicians and their patients in these 2 groups using standardized differences. RESULTS We analyzed 9060 family physicians with 10 837 909 enrolled patients. Family physicians with the largest proportion (top 10%) of unvaccinated patients (n = 906) were more likely to be male, to have trained outside of Canada, to be older, and to work in an enhanced fee-for-service model than those in the remaining 90%. Vaccine coverage (≥ 2 doses of SARS-CoV-2 vaccine) was 74% among patients of physicians with the largest proportion of unvaccinated patients, compared with 87% in the remaining patient population. Patients in the top 10% group tended to be younger and live in areas with higher levels of ethnic diversity and immigration and lower incomes. INTERPRETATION Primary care practices with the largest proportion of patients unvaccinated against SARS-CoV-2 served marginalized communities and were less likely to use team-based care models. These findings can guide resource planning and help tailor interventions to integrate public health priorities within primary care practices.
Collapse
Affiliation(s)
- Jennifer Shuldiner
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont.
| | - Michael E Green
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Tara Kiran
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Shahriar Khan
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Eliot Frymire
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Rahim Moineddin
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Meghan Kerr
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Mina Tadrous
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Dominik Alex Nowak
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Jeffrey C Kwong
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Jia Hu
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Holly O Witteman
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Bryn Hamilton
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Isaac Bogoch
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Lydia-Joy Marshall
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Sophia Ikura
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Stacey Bar-Ziv
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - David Kaplan
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Noah Ivers
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| |
Collapse
|
2
|
Holladay EE, Mudano AS, Xie F, Stewart P, Jackson LE, Danila MI, Gavigan K, Nowell WB, Venkatachalam S, Curtis JR. COVID-19 Vaccine Uptake, Hesitancy, and Flare in a Large Rheumatology Practice Network. Arthritis Care Res (Hoboken) 2024; 76:111-119. [PMID: 37750035 DOI: 10.1002/acr.25241] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 09/13/2023] [Accepted: 09/18/2023] [Indexed: 09/27/2023]
Abstract
OBJECTIVE The goal of this study was to ascertain COVID-19 vaccine uptake, reasons for hesitancy, and self-reported flare in a large rheumatology practice-based network. METHODS A tablet-based survey was deployed by 108 rheumatology practices from December 2021 to December 2022. Patients were asked about COVID-19 vaccine status and why they might not receive a vaccine or booster. We used descriptive statistics to explore the differences between vaccination status and vaccine and booster hesitancy, comparing patients with and without autoimmune and inflammatory rheumatic diseases (AIIRDs). We used multivariable logistic regression to examine the association between vaccine uptake and AIIRD status and self-reported flare and AIIRD status. We reported adjusted odds ratios (aORs). RESULTS Of the 61,158 patients, 89% reported at least one dose of vaccine; of the vaccinated, 68% reported at least one booster. Vaccinated patients were less likely to have AIIRDs (44% vs 56%). A greater proportion of patients with AIIRDs were vaccine hesitant (14% vs 10%) and booster hesitant (21% vs 16%) compared to patients without AIIRDs. Safety concerns (28%) and side effects (23%) were the main reasons for vaccine hesitancy, whereas a lack of recommendation from the physician was the primary factor for booster hesitancy (23%). Patients with AIIRD did not have increased odds of self-reported flare or worsening disease compared to patients without with AIIRD (aOR 0.99, 95% confidence interval [CI] 0.94-1.05). Among the patients who were vaccine hesitant and booster hesitant, 12% and 39% later reported receiving a respective dose. Patients with AIIRD were 32% less likely to receive a vaccine (aOR 0.68, 95% CI 0.65-0.72) versus patients without AIIRD. CONCLUSION Some patients who are vaccine and booster hesitant eventually receive a vaccine dose, and future interventions tailored to patients with AIIRD may be fruitful.
Collapse
Affiliation(s)
| | | | | | | | | | - Maria I Danila
- University of Alabama at Birmingham and Birmingham Department of Veterans Affairs Medical Center, Birmingham, Alabama
| | - Kelly Gavigan
- Global Healthy Living Foundation, Upper Nyack, New York
| | | | | | - Jeffrey R Curtis
- University of Alabama at Birmingham and Illumination Health, Hoover, Alabama
| |
Collapse
|
3
|
Rush M, Hyman C, Yonts A, Szeles R, Boogaard C. Pediatric COVID-19 Vaccination in the Inpatient Setting. Hosp Pediatr 2023; 13:e329-e332. [PMID: 37807862 DOI: 10.1542/hpeds.2022-006804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
BACKGROUND AND OBJECTIVES The inpatient setting is often underutilized as a venue for providing pediatric vaccines. During the 2019 novel coronavirus (COVID-19) pandemic, our hospital began a vaccination program to provide access to COVID-19 vaccines for eligible pediatric inpatients. Our objective was to describe the establishment and assess the impact of a COVID-19 vaccination program for pediatric inpatients. METHODS All admitted patients were screened for eligibility and interest in inpatient COVID-19 vaccination upon admission from April 27, 2021 until February 12, 2022. For those eligible for vaccination, their interest was recorded and shared with the clinical team. The clinical team completed education and/or vaccination depending on individual case. Interest in inpatient vaccination and ultimate receipt of a vaccine was recorded and analyzed. RESULTS During the study period, 1615 patients were eligible for inpatient vaccination and 1601 had their interest recorded on hospital admission. Twenty-one percent of these patients were interested, 50% declined, and 28% were unsure. Twenty-nine percent of those initially interested were given vaccine by the clinical team before discharge. Six percent of patients who were unsure and 2% of those who declined vaccine on admission were vaccinated before discharge. CONCLUSIONS The inpatient setting can be an important venue to allow for education and discussion regarding pediatric COVID-19 vaccine and to improve access to vaccination for a traditionally under-vaccinated population. Challenges remain with consistent vaccine administration even for interested pediatric inpatients.
Collapse
Affiliation(s)
| | - Cleopatra Hyman
- Department of Case Management and Revenue Cycle, Children's National Hospital, Washington, District of Columbia
| | | | - Rosemary Szeles
- Children's National Hospital, Washington, District of Columbia
| | | |
Collapse
|
4
|
Nuzhath T, Spiegelman A, Scobee J, Goidel K, Washburn D, Callaghan T. Primary care physicians' strategies for addressing COVID-19 vaccine hesitancy. Soc Sci Med 2023; 333:116150. [PMID: 37595423 DOI: 10.1016/j.socscimed.2023.116150] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 08/02/2023] [Accepted: 08/04/2023] [Indexed: 08/20/2023]
Abstract
OBJECTIVE To explore the strategies that primary care physicians use to address patient COVID-19 vaccine hesitancy. METHOD We administered an online survey to 625 primary care physicians from May 14 to May 25, 2021, to assess the messages that primary care physicians use to encourage hesitant patients to get vaccinated against COVID-19.589 physicians from the total pool of 625 provided open-ended responses. We conducted thematic content analysis on the responses based on previous research and themes identified within the data. SETTING The survey was administered online using the survey research firm Dynata. RESULTS Eleven primary themes emerged from our analysis, which included, physicians addressing specific concerns about vaccine safety (including costs versus benefits), physicians helping patients understand what it means to remain unvaccinated, or whether physicians try to connect emotionally through the use of guilt, or personal experience, whether physicians use derisive language to communicate with unvaccinated patients. In addition, a small number of physicians indicated they would not attempt to persuade someone who is vaccine hesitant. CONCLUSIONS Our study shows that while some of the physicians used different strategies to address vaccine hesitancy, some of the physicians used harsh language or did not make any effort to reduce COVID-19 related vaccine hesitancy among their patients. Focused advocacy and training are needed to increase physician engagement in vaccine-related dialogues with their patients. Such efforts will ensure that critical opportunities for patient education and awareness-building are not missed and ensure high levels of vaccination uptake.
Collapse
Affiliation(s)
- Tasmiah Nuzhath
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health. Huntington Ave, Boston, MA, 02115, USA; Department of Health Promotion and Community Health Sciences, School of Public Health, Texas A&M University. 212 Adriance Lab Rd. 1266 TAMU, College Station, TX, USA.
| | | | - Julia Scobee
- Department of Health Law, Policy and Management, School of Public Health, Boston University, 715 Albany Street, Boston, MA, USA
| | - Kirby Goidel
- Department of Political Science, Texas A&M University, 2935, Research Pkwy, College Station, TX, USA
| | - David Washburn
- Department of Health Policy and Management, School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, New Orleans, LA, USA
| | - Timothy Callaghan
- Department of Health Law, Policy and Management, School of Public Health, Boston University, 715 Albany Street, Boston, MA, USA
| |
Collapse
|
5
|
Moore R, Purvis RS, CarlLee S, Hallgren E, Kraleti S, Willis DE, McElfish PA. Understanding Vaccination Among Hesitant Adopters of the COVID-19 Vaccine Using the Increasing Vaccination Model. JOURNAL OF HEALTH COMMUNICATION 2023; 28:458-476. [PMID: 37394866 PMCID: PMC10443235 DOI: 10.1080/10810730.2023.2224265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
The coronavirus disease (COVID-19) was the third leading cause of death in 2021 in the United States and has led to historic declines in life expectancy for Americans. While vaccination is an effective mitigation strategy for COVID-19, vaccine hesitancy remains a major barrier to individual and population-level protection. An emerging literature on hesitant adopters of COVID-19 vaccines highlights co-occurrence of hesitancy and vaccine uptake as an understudied phenomenon, with the potential to provide insight into factors that lead hesitant individuals to become vaccinated despite their hesitancy. We use qualitative interviews among hesitant adopters in Arkansas to examine vaccine hesitancy among this understudied group. Drawing on the Increasing Vaccination Model, we find that the most frequently reported motivations of hesitant adopters were within the domain of social processes, pointing to a critical focal point for targeted health communications intervening in this domain (e.g. social norms, social networks, and altruistic behavior). We find that recommendations from health care workers (HCWs) other than physicians/providers may serve as an effective influence to vaccinate. We also demonstrate negative effects of low provider and HCW confidence and weak recommendations on motivations to vaccinate among individuals expressing vaccine hesitancy. Additionally, we find individual information-seeking behaviors among hesitant adopters bolstered confidence in the efficacy of the COVID-19 vaccine. Based on these findings, clear, accessible, and authoritative health communication has a role in combatting the COVID-19 misinformation/disinformation infodemic.
Collapse
Affiliation(s)
- Ramey Moore
- College of Medicine, University of Arkansas for Medical Sciences Northwest, Springdale, Arkansas, USA
| | - Rachel S Purvis
- College of Medicine, University of Arkansas for Medical Sciences Northwest, Springdale, Arkansas, USA
| | - Sheena CarlLee
- College of Medicine, University of Arkansas for Medical Sciences Northwest, Fayetteville, Arkansas, USA
| | - Emily Hallgren
- College of Medicine, University of Arkansas for Medical Sciences Northwest, Springdale, Arkansas, USA
| | - Shashank Kraleti
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Don E Willis
- College of Medicine, University of Arkansas for Medical Sciences Northwest, Springdale, Arkansas, USA
| | - Pearl A McElfish
- College of Medicine, University of Arkansas for Medical Sciences Northwest, Springdale, Arkansas, USA
| |
Collapse
|
6
|
Okada H, Okuhara T, Goto E, Kiuchi T. Association between trust in COVID-19 information sources and engaging in infection prevention behaviors in Japan: A longitudinal study. PATIENT EDUCATION AND COUNSELING 2023; 111:107686. [PMID: 36857804 PMCID: PMC9957338 DOI: 10.1016/j.pec.2023.107686] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 02/08/2023] [Accepted: 02/23/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE We examined changes in people's trust in information sources in Japan during the COVID-19 pandemic over the course of 1 year and investigated longitudinal associations between trust in such sources and engaging in infection prevention behaviors. METHODS We conducted a longitudinal survey of Japanese populations under a declared state of emergency at two time points, August 2020 and August 2021. We surveyed sociodemographic data, seven Trust in COVID-19 information sources and six COVID-19 preventive behaviors. RESULTS In all, 784 participants completed the two surveys. Physicians were the most consistently trusted information source over the 1-year period. We identified three preventive behaviors that were positively associated with trust in physicians as an information source (social distancing, wearing masks, and washing hands with soap), four preventive behaviors that were positively associated with trusting infected patients (social distancing, using ventilation, wearing masks, and using hand sanitizer), and one preventative behavior that was negatively associated with trust in government (avoiding closed spaces). CONCLUSION In the ongoing pandemic, information from physicians and patients may encourage people to engage in long-term preventive behaviors. PRACTICE IMPLICATIONS Physicians and patients should be promoted as trusted and behavior influencing sources of information during the pandemic.
Collapse
Affiliation(s)
- Hiroko Okada
- Department of Health Communication, School of Public Health, The University of Tokyo, Tokyo, Japan.
| | - Tsuyoshi Okuhara
- Department of Health Communication, School of Public Health, The University of Tokyo, Tokyo, Japan.
| | - Eiko Goto
- Department of Health Communication, School of Public Health, The University of Tokyo, Tokyo, Japan.
| | - Takahiro Kiuchi
- Department of Health Communication, School of Public Health, The University of Tokyo, Tokyo, Japan.
| |
Collapse
|
7
|
Alcendor DJ, Matthews-Juarez P, Smoot D, Edwards A, Hildreth JEK, Juarez PD. Vaccine Confidence and Uptake of the Omicron Bivalent Booster in Tennessee: Implications for Vulnerable Populations. Vaccines (Basel) 2023; 11:vaccines11050906. [PMID: 37243010 DOI: 10.3390/vaccines11050906] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/19/2023] [Accepted: 04/24/2023] [Indexed: 05/28/2023] Open
Abstract
The COVID-19 Omicron variant and its subvariants are now the dominant variants circulating in the US. Therefore, the original COVID-19 vaccine cannot offer full protection. Instead, vaccines that target the spike proteins of the Omicron variants are warranted. Hence, the FDA recommended the development of a bivalent booster. Unfortunately, despite the safety and immunogenicity of the Omicron bivalent boosters from Pfizer and Moderna, uptake in the US has been poor. At this time, only 15.8% of individuals in the US aged five and older have received the Omicron bivalent booster (OBB). The rate is 18% for those aged 18 and older. Poor vaccine confidence and booster uptake are often fueled by misinformation and vaccine fatigue. These result in more problems associated with vaccine hesitancy, which are particular prevalent in Southern states in the US. In Tennessee, the OBB vaccination rate for eligible recipients is only 5.88% at time of writing (16 February 2023). In this review, we discuss (1) the rationale for developing the OBBs; (2) the efficacy and safety of the bivalent boosters; (3) the adverse events associated with these boosters; (4) vaccine hesitancy associated with the OBBs uptake in Tennessee; (5) implications for vulnerable populations, disparities in uptake of OBBs in Tennessee, and strategies to improve vaccine confidence and OBB uptake. In support of public health, it is essential that we continue to provide education, awareness, and vaccine access to the vulnerable and medically underserved populations in Tennessee. Receiving the OBBs is the most effective method to date of protecting the public against severe COVID disease, hospitalization, and death.
Collapse
Affiliation(s)
- Donald J Alcendor
- Department of Microbiology, Immunology, and Physiology, Center for AIDS Health Disparities Research, School of Medicine, Meharry Medical College, 1005 Dr. D.B. Todd Jr. Blvd., Nashville, TN 37208, USA
| | - Patricia Matthews-Juarez
- Department of Family & Community Medicine, Meharry Medical College, 1005 D.B. Todd Jr. Blvd., Nashville, TN 37208, USA
| | - Duane Smoot
- Department of Internal Medicine, School of Medicine, Meharry Medical College, 1005 D.B. Todd Jr. Blvd., Nashville, TN 37208, USA
| | - Alexis Edwards
- Office of Minority Health, Division of Health Disparities, Tennessee Department of Health, Nashville, TN 37208, USA
| | - James E K Hildreth
- Department of Microbiology, Immunology, and Physiology, Center for AIDS Health Disparities Research, School of Medicine, Meharry Medical College, 1005 Dr. D.B. Todd Jr. Blvd., Nashville, TN 37208, USA
| | - Paul D Juarez
- Department of Family & Community Medicine, Meharry Medical College, 1005 D.B. Todd Jr. Blvd., Nashville, TN 37208, USA
| |
Collapse
|
8
|
Associated factors to human papillomavirus vaccine adhesion in adult women: a cross-sectional study. Porto Biomed J 2023; 8:e181. [DOI: 10.1097/j.pbj.0000000000000181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 01/26/2022] [Indexed: 02/10/2023] Open
|
9
|
Askarian M, Fu LY, Taghrir MH, Borazjani R, Shayan Z, Taherifard E, Taherifard E, Akbarialiabad H, Longtin Y, Askarian A, Kavousi S. COVID-19 Vaccination Acceptance in Iran, a Nationwide Survey on Factors Associated with the Willingness toward Getting Vaccinated. Int J Prev Med 2022; 13:130. [PMID: 36452471 PMCID: PMC9704476 DOI: 10.4103/ijpvm.ijpvm_261_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/28/2021] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND In the name of extensive vaccine uptake, understanding the public's attitude, perception, and intent toward COVID-19 vaccination is a significant challenge for public health officials. METHODS A cross-sectional survey via an online questionnaire rooted in the Health Belief Model and Integrated Behavioral Model was conducted to evaluate COVID-19 vaccination intent and its associated factors. Factor analysis and multivariate logistic regression were operated to be satisfactory. RESULTS Among the 4,933 respondents, 24.7% were health care workers, and 64.2% intended to accept COVID-19 vaccination. The adjusted odds (aOR) of COVID-19 vaccination intent was higher for individuals with greater exposure to social norms supportive of COVID-19 vaccination (aOR = 3.07, 95% Confidence Interval (CI) = 2.71, 3.47) and higher perceived benefits of COVID-19 vaccination (aOR = 2.9, 95% CI = 2.49, 3.38). The adjusted odds of vaccination intent were lower for individuals with greater COVID-19 vaccine safety concerns (aOR = 0.28, 95%CI = 0.25, 0.31). Lower vaccination intent was also associated with increasing age ((aOR = 0.99, 95% CI = 0.98, 0.999), female sex (aOR = 0.76, 95% CI = 0.65, 0.88), and working in the health care field (aOR = 0.75, 95% CI = 0.63, 0.9). CONCLUSIONS The odds of COVID-19 vaccination intent were higher three or more times among those with a greater belief in vaccine effectiveness, lower concerns about vaccine safety, and greater exposure to cues to vaccinate, including from doctors. This last finding is concerning as vaccine acceptance was surprisingly lower among health care workers compared to others. The remarkable results of factor analysis and reliability of the questionnaire may encourage local health authorities to apply it to their regional population.
Collapse
Affiliation(s)
- Mehrdad Askarian
- Department of Community Medicine, School of Medicine, Shiraz, Iran
- Health Behavior Science Research Center, Shiraz, Iran
| | - Linda Y. Fu
- General and Community Pediatrics, Children's National Hospital, 111 Michigan Ave., NW, Washington, DC 20010, USA
| | - Mohammad Hossein Taghrir
- Student Research Committee, School of Medicine, Shiraz University of Medical Sciences and Health Services, Shiraz, Iran
| | - Roham Borazjani
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Shayan
- Trauma Research Center, Department of Biostatistics, School of Medicine, Shiraz, Iran
| | - Ehsan Taherifard
- Medical Student, School of Medicine, Shiraz University of Medical Sciences and Health Services, Shiraz, Iran
| | - Erfan Taherifard
- Medical Student, School of Medicine, Shiraz University of Medical Sciences and Health Services, Shiraz, Iran
| | - Hossein Akbarialiabad
- Student Research Committee, School of Medicine, Shiraz University of Medical Sciences and Health Services, Shiraz, Iran
| | - Yves Longtin
- Department of Medicine, Jewish General Hospital, McGill University, Montreal, Canada
| | - Ardalan Askarian
- Student, College of Arts & Science, University of Saskatchewan, Saskatoon, Canada
| | - Shahin Kavousi
- Student Research Committee, School of Medicine, Shiraz University of Medical Sciences and Health Services, Shiraz, Iran
| |
Collapse
|
10
|
Desalermos A, Pimienta M, Kalligeros M, Shehadeh F, Diamantopoulos L, Karamanolis G, Caldera F, Farraye FA. Safety of Immunizations for the Adult Patient With Inflammatory Bowel Disease-A Systematic Review and Meta-analysis. Inflamm Bowel Dis 2022; 28:1430-1442. [PMID: 34849941 DOI: 10.1093/ibd/izab266] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) have low vaccination rates for vaccine-preventable diseases. Fear of adverse reactions (AEs) appear to negatively affect vaccination efforts. We aimed to systemically review the risks for AEs following immunization for patients with IBD. METHODS We searched PubMed and Embase until April 15, 2020, for studies evaluating the safety of vaccinations among patients with IBD. The primary outcome was the incidence of systemic and local AEs among vaccinated patients. Secondary outcome was the rate of IBD flare following immunization. We utilized a random effects meta-analysis of proportions using the DerSimonian-Laird approach to estimate the safety of immunizations. RESULTS A total of 13 studies with 2116 patients was included in our analysis after fulfilling our inclusion criteria. Seven studies examined the influenza vaccine, 4 the pneumococcal vaccine, 1 the recombinant zoster vaccine, and 1 the hepatitis B vaccine. Follow-up of patients was up to 6 months. The majority of AEs were local, with a pooled incidence of 24% (95% CI, 9%-42%) for all vaccines. Systemic AEs were mostly mild, without resulting in hospitalizations or deaths, with a pooled incidence of 16% (95% CI, 6%-29%) for all vaccines. Flare of inflammatory bowel disease after vaccination found with a pooled incidence of 2% (95% CI, 1%-4%) and we include in the analysis data from all immunizations examined. DISCUSSION Our study demonstrated that AEs after vaccination are mainly local or mildly systemic and do not differ significantly from the expected AE after recommended immunizations for the general population. Thus, gastroenterologists should reinforce that vaccines are safe in patients with IBD.
Collapse
Affiliation(s)
- Athanasios Desalermos
- University of Massachusetts Medical School, Center for Digestive Wellness, Worcester, MA, USA
| | - Michael Pimienta
- The Keck School of Medicine at University of Southern California, Los Angeles, CA, USA
| | - Markos Kalligeros
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Fadi Shehadeh
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | | | - Freddy Caldera
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Francis A Farraye
- Inflammatory Bowel Disease Center, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| |
Collapse
|
11
|
“I Would Never Push a Vaccine on You”: A Qualitative Study of Social Norms and Pressure in Vaccine Behavior in the U.S. Vaccines (Basel) 2022; 10:vaccines10091402. [PMID: 36146480 PMCID: PMC9502292 DOI: 10.3390/vaccines10091402] [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: 07/31/2022] [Revised: 08/19/2022] [Accepted: 08/20/2022] [Indexed: 12/16/2022] Open
Abstract
Previous researchers have established the influence of social norms on vaccine behavior. However, little work has been performed contextualizing individuals’ experience with these social factors and how they operate to persuade individuals’ acceptance or refusal of a vaccine. We aimed to determine the mechanisms of familial and societal pressure or expectations that contribute to COVID-19 vaccine decision-making. We conducted four focus groups and eleven individual interviews (total n = 32) with participants from across the U.S. of different vaccination statuses. We identified three emergent themes: (1) Altruistic reasoning was particularly prevalent among initially hesitant late adopters—the desire to protect loved ones and others constituted a dominant motive, more powerful than protecting oneself. Vaccination was also reckoned as part of a joint effort to return to normal life; hence, it invoked a sense of responsibility or “obligation”; (2) expectation often became pressure; although most vaccinated participants stated that they respected others’ choices, late adopters or unvaccinated participants perceived differently and felt rushed or “forced” into choosing, and many resented being “targeted” or “bullied”; (3) vaccination status became a new label, frequently dividing families, thus producing familial mandates, exclusions, or social stratifications. This caused sadness and feelings of isolation, along with the formation of a camaraderie among the excluded unvaccinated. A vaccine decision builds from the complexities of individuals’ experiences and cultures. The vaccinated were not free of hesitancy nor were the unvaccinated all anti-vaxxers. Vigorous vaccine promotion successfully converted some undecided individuals but also fostered distrust of government; alarmingly, the push to receive the COVID-19 vaccine further triggered doubts about established vaccines. Communication strategies need to be developed and implemented carefully so as not to ostracize the unvaccinated community and strengthen their resistance.
Collapse
|
12
|
Hussain B, Latif A, Timmons S, Nkhoma K, Nellums LB. Overcoming COVID-19 vaccine hesitancy among ethnic minorities: A systematic review of UK studies. Vaccine 2022; 40:3413-3432. [PMID: 35534309 PMCID: PMC9046074 DOI: 10.1016/j.vaccine.2022.04.030] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 03/09/2022] [Accepted: 04/06/2022] [Indexed: 12/31/2022]
Abstract
Ethnic minority communities in the UK have been disproportionately affected by the pandemic, with increased risks of infection, severe disease, and death. Hesitancy around the COVID-19 vaccine may be contributing to disparities in vaccine delivery to ethnic minority communities. This systematic review aims to strengthen understanding of COVID-19 vaccine concerns among ethnic minorities in the UK. Five databases were searched in February 2022, yielding 24 peer-reviewed studies reporting on vaccine hesitancy or acceptance in ethnic minority groups. Data were extracted using a standardised form, and quality assessment was carried out using the Standard Quality Criteria. There were three key themes: (1). Prevalence of vaccine hesitancy; (2). Reasons for vaccine hesitancy and acceptance; and (3). Recommendations to address vaccine concerns. Vaccine hesitancy, which was more common among some ethnic minority groups, is a complex phenomenon, driven by misinformation, mistrust, concerns about safety and efficacy, and structural and systemic inequities. Community engagement and tailored communication may help to address vaccine concerns. Robust data disaggregated by ethnicities are needed to better understand barriers and facilitators for COVID-19 vaccine delivery in ethnic minority communities. Strategies to address structural disadvantage need to be inclusive, comprehensive, and behaviorally informed and foster confidence in healthcare systems and governments. Community leaders and health care practitioners may prove to be the most important agents in creating an environment of trust within ethnic minority groups.
Collapse
|
13
|
Day P, Strenth C, Kale N, Schneider FD, Arnold EM. Perspectives of primary care physicians on acceptance and barriers to COVID-19 vaccination. Fam Med Community Health 2021; 9:fmch-2021-001228. [PMID: 34740897 PMCID: PMC8573291 DOI: 10.1136/fmch-2021-001228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES The purpose of this study was to examine the perspectives of primary care physicians in Texas around vaccine acceptance and potential patient barriers to vaccination. National surveys have shown fluctuating levels of acceptance for COVID-19 vaccination, and primary care physicians could play a crucial role in increasing vaccine uptake. DESIGN This study employed a cross-sectional anonymous survey design to collect data using an online questionnaire. Participants were asked about vaccination practices and policies at their practice site, perceptions of patient and community acceptance and confidence in responding to patient vaccine concerns. SETTING From November 2020 to January 2021, family medicine physicians and paediatricians completed an online questionnaire on COVID-19 vaccination that was distributed by professional associations. PARTICIPANTS The survey was completed by 573 practising physicians, the majority of whom identified as family medicine physicians (71.0%) or paediatricians (25.7%), who are currently active in professional associations in Texas. RESULTS About three-fourths (74.0%) of participants reported that they would get the vaccine as soon as it became available. They estimated that slightly more than half (59.2%) of their patients would accept the vaccine, and 67.0% expected that the COVID-19 vaccine would be accepted in their local community. The majority of participants (87.8%) reported always, almost always or usually endorsing vaccines, including high levels of intention to recommend COVID-19 vaccination (81.5%). Participants felt most confident responding to patient concerns related to education about vaccine types, safety and necessity and reported least confidence in responding to personal or religious objections to COVID-19 vaccination. CONCLUSIONS The majority of the physicians surveyed stated that they would receive the COVID-19 vaccination when it was available to them and were confident in their ability to respond to patient concerns. With additional education, support and shifting COVID-19 vaccinations into primary care settings, primary care physicians can use the trust they have built with their patients to address vaccine hesitancy and potentially increase acceptance and uptake.
Collapse
Affiliation(s)
- Philip Day
- Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Chance Strenth
- Department of Family and Community Medicine, UT Southwestern Medical School, Dallas, Texas, USA
| | - Neelima Kale
- Department of Family and Community Medicine, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - F David Schneider
- Department of Family and Community Medicine, The University of Texas Southwestern Medical Center Medical School, Dallas, Texas, USA
| | | |
Collapse
|
14
|
Perceptions of COVID-19 vaccines in a predominantly Hispanic patient population from the Texas-Mexico border. J Am Pharm Assoc (2003) 2021; 62:S17-S21.e2. [PMID: 34862142 PMCID: PMC8570390 DOI: 10.1016/j.japh.2021.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/30/2021] [Accepted: 11/02/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND Compared with nationwide averages, Hispanic individuals have experienced lower routine vaccination rates and have been disproportionately hospitalized for coronavirus disease 2019 (COVID-19). Few, if any, studies have examined the health beliefs surrounding the COVID-19 vaccines and adult vaccines among this population. OBJECTIVES This study aimed to (1) describe perceptions of COVID-19 vaccines in a predominantly Hispanic patient population in a federally qualified health center (FQHC) situated on the United States-Mexico border and (2) compare patient confidence in recommendations made by local clinic and government to obtain adult and COVID-19 vaccines. METHODS A bilingual (English or Spanish) written survey was administered to participants recruited from a convenience sample of patients in waiting areas of 4 clinic sites in an FQHC system on the Texas-Mexico border between March and May 2021. Survey items were derived from the Health Belief Model and captured beliefs surrounding perceived effectiveness, perceived harms, protection from the influenza vaccine, trust in the local clinic, and trust in the government. RESULTS A total of 58 participants aged 19-90 years, with a mean age of 57.28 years, completed the survey between March and May 2021, with 77.6% of respondents indicating they would accept a COVID-19 vaccine for themselves. Results revealed a trend among older adults in the study cohort to be more likely to trust the government in recommending vaccines than younger adults (r = 0.33, P ≤ 0.05) and a tendency toward higher vaccine acceptance among male survey participants (P = 0.026). The highest correlation that emerged was between perceived trust in local clinic provider and the perceived effectiveness of vaccines (r = 0.74, P < 0.01). CONCLUSION Trends related to perceptions of adult vaccines among Hispanic patients extend to the COVID-19 vaccines: especially trust in local clinic providers. Increased age may correlate to higher trust in a government-recommended vaccine. Results highlight the importance of the pharmacist giving the patient a clear recommendation to receive vaccination and strong local clinic messaging.
Collapse
|
15
|
Kidney Transplant Recipient Attitudes Toward a SARS-CoV-2 Vaccine. Transplant Direct 2021; 7:e713. [PMID: 34131585 PMCID: PMC8196090 DOI: 10.1097/txd.0000000000001171] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/25/2021] [Accepted: 04/08/2021] [Indexed: 11/26/2022] Open
Abstract
A widely accepted severe acute respiratory syndrome 2 (SARS-CoV-2) vaccine could protect vulnerable populations, but the willingness of solid organ transplant recipients (SOTRs) to accept a potential vaccine remains unknown. Methods We conducted a national survey of 1308 SOTRs and 1617 non-SOTRs between November 11 and December 2, 2020 through the network of the National Kidney Foundation. Results Respondents were largely White (73.2%), female (61.1%), and college graduates (56.2%). Among SOTRs, half (49.5%) were unsure or would be unwilling to receive a SARS-CoV-2 vaccine once available. Major concerns included potential side effects (85.2%), lack of rigor in the testing and development process (69.7%), and fear of incompatibility with organ transplants (75.4%). Even after the announcement of the high efficacy of the mRNA-1273 vaccine (Moderna Inc.) at the time of survey distribution, likeliness to receive a vaccine only slightly increased (53.5% before announcement versus 57.8% after the announcement). However, 86.8% of SOTRs would accept a vaccine if recommended by a transplant provider. Conclusions SOTRs reported skepticism in receiving a potential SARS-CoV-2 vaccine, even after announcements of high vaccine efficacy. Reassuringly, transplant providers may be the defining influence in vaccine acceptance and will likely have a critical role to play in promoting vaccine adherence.
Collapse
|
16
|
McFadden SM, Ko LK, Shankar M, Ibrahim A, Berliner D, Lin J, Mohamed FB, Amsalu F, Ali AA, Jang SH, Winer RL. Development and evaluation of an online continuing education course to increase healthcare provider self-efficacy to make strong HPV vaccine recommendations to East African immigrant families. Tumour Virus Res 2021; 11:200214. [PMID: 33647533 PMCID: PMC7944093 DOI: 10.1016/j.tvr.2021.200214] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 02/03/2021] [Accepted: 02/17/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To develop and evaluate an online continuing education (CE) course designed to improve healthcare provider self-efficacy to make strong adolescent HPV vaccine recommendations to East African immigrant families. METHODS Focus groups with providers and East African immigrant mothers informed course development. Providers serving East African immigrant families were recruited to view the course and complete pre-/post-test and two-month follow-up surveys. Pre-/post differences were compared with paired t-tests. RESULTS 202 providers completed the course and pre-/post-test; 158 (78%) completed two-month follow-up. Confidence to make strong HPV vaccine recommendations to East African families increased from 68% pre-test to 98% post-test. Confidence to address common parental concerns also increased: safety, 54% pre-test, 92% post-test; fertility, 55% pre-test, 90% post-test; child too young, 68% pre-test, 92% post-test; and pork gelatin in vaccine manufacturing, 38% pre-test, 90% post-test. Two-month follow-up scores remained high (97% for overall confidence, 94%-97% for addressing parental concerns). All pre-/post-test and pre-test/two-month follow-up comparisons were statistically significant (p < 0.05). CONCLUSIONS The online CE course focused on culturally appropriate strategies for making strong recommendations and addressing specific parental concerns was effective for increasing provider self-efficacy to recommend HPV vaccination to East African families. Similar courses could be tailored to other priority populations.
Collapse
Affiliation(s)
- SarahAnn M McFadden
- University of Washington School of Nursing, 1959 NE Pacific St, Box 357260, Seattle, WA, 98195, USA.
| | - Linda K Ko
- Division of Public Health Services, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, M3-B232, Seattle, WA, 98102, USA; Department of Health Services, University of Washington School of Public Health, 3980 15th, Ave NE, Box 351621, Seattle, WA, 98195, USA.
| | - Megha Shankar
- Department of Medicine, University of Washington, 1959 NE Pacific St, Box 356421, Seattle, WA, 98195, USA.
| | - Anisa Ibrahim
- Department of Pediatrics, University of Washington, 1959 NE Pacific St, Box 356320, Seattle, WA, 98104, USA; Somali Health Board, 7050 32nd, AVE S, Seattle, WA, 98118, USA.
| | - Debra Berliner
- Public Health - Seattle & King County, Communicable Disease, Epidemiology, and Immunization Program, 401 5th(,) Ave., Seattle, WA, 98104, USA.
| | - John Lin
- Department of Epidemiology, University of Washington School of Public Health, 3980 15th, Ave NE, Box 351619, Seattle, WA, 98195, USA.
| | - Farah B Mohamed
- Somali Health Board, 7050 32nd, AVE S, Seattle, WA, 98118, USA; Department of Epidemiology, University of Washington School of Public Health, 3980 15th, Ave NE, Box 351619, Seattle, WA, 98195, USA.
| | - Fanaye Amsalu
- Department of Epidemiology, University of Washington School of Public Health, 3980 15th, Ave NE, Box 351619, Seattle, WA, 98195, USA.
| | - Ahmed A Ali
- Somali Health Board, 7050 32nd, AVE S, Seattle, WA, 98118, USA.
| | - Sou Hyun Jang
- Department of Sociology, Sungkyunkwan University, 25-2 Sungkyunkwan-ro, Jongno-gu, Seoul, 03063, South Korea.
| | - Rachel L Winer
- Department of Epidemiology, University of Washington School of Public Health, 3980 15th, Ave NE, Box 351619, Seattle, WA, 98195, USA.
| |
Collapse
|
17
|
Caldwell AC, Madden CA, Thompson DM, Garbe MC, Roberts JR, Jacobson RM, Darden PM. The impact of provider recommendation on human papillomavirus vaccine and other adolescent vaccines. Hum Vaccin Immunother 2021; 17:1059-1067. [PMID: 33074774 DOI: 10.1080/21645515.2020.1817713] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
This study explored the association between provider recommendation and adolescent vaccine coverage. We analyzed data from the 2008 to 2018 National Immunization Survey-Teen including coverage with one dose of quadrivalent meningococcal conjugate vaccine (MenACWY), Tetanus-diphtheria-acellular pertussis vaccine (Tdap), and one and three doses of Human papillomavirus (HPV) vaccine. We compared vaccine coverage between those who recalled a provider recommendation and those who did not. Among those who received a provider recommendation for MenACWY, coverage trended from 67.8% (2008) to 88.1% (2013), contrasted to those who did not, trending from 30.9% to 73.1%. Among those with a provider recommendation for Tdap, coverage trended from 47.6% to 89.7%, contrasted to those who did not, trending from 35.6% to 82.2%. Among females with a provider recommendation for HPV vaccine, receipt of initial dose of HPV vaccine trended from 57.5% (2008) to 74.3% (2018), contrasted to those who did not, trending from 18.1% to 49.8%, and among males, trended from 17.2% (2010) to 75.1% (2018) for those with a provider recommendation, compared to 0.5% to 44.7% for those without. In 2013, coverage difference by provider recommendation was 26.0% among females for one dose of HPV vaccine and 21.9% for three doses, and among males was 44.8% and 20.8%, respectively, while it was lower at 15% for MenACWY and 7.6% for Tdap. For each vaccine, coverage was higher with a provider recommendation; the largest difference was noted for HPV vaccine. This finding verifies for providers the importance of their recommendation, especially for the HPV vaccine.
Collapse
Affiliation(s)
- Alexandria C Caldwell
- Department of Pediatrics, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Christi A Madden
- Department of Pediatrics, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - David M Thompson
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - M Connor Garbe
- Department of Pediatrics, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - James R Roberts
- Department of Pediatrics, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Robert M Jacobson
- Mayo Clinic, Department of Pediatric and Adolescent Medicine, Rochester, MN, USA
| | - Paul M Darden
- Department of Pediatrics, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| |
Collapse
|
18
|
Finney Rutten LJ, Zhu X, Leppin AL, Ridgeway JL, Swift MD, Griffin JM, St Sauver JL, Virk A, Jacobson RM. Evidence-Based Strategies for Clinical Organizations to Address COVID-19 Vaccine Hesitancy. Mayo Clin Proc 2021; 96:699-707. [PMID: 33673921 PMCID: PMC7772995 DOI: 10.1016/j.mayocp.2020.12.024] [Citation(s) in RCA: 166] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 12/28/2020] [Indexed: 12/24/2022]
Abstract
The success of vaccination programs is contingent upon irrefutable scientific safety data combined with high rates of public acceptance and population coverage. Vaccine hesitancy, characterized by lack of confidence in vaccination and/or complacency about vaccination that may lead to delay or refusal of vaccination despite the availability of services, threatens to undermine the success of coronavirus disease 2019 (COVID-19) vaccination programs. The rapid pace of vaccine development, misinformation in popular and social media, the polarized sociopolitical environment, and the inherent complexities of large-scale vaccination efforts may undermine vaccination confidence and increase complacency about COVID-19 vaccination. Although the experience of recent lethal surges of COVID-19 infections has underscored the value of COVID-19 vaccines, ensuring population uptake of COVID-19 vaccination will require application of multilevel, evidence-based strategies to influence behavior change and address vaccine hesitancy. Recent survey research evaluating public attitudes in the United States toward the COVID-19 vaccine reveals substantial vaccine hesitancy. Building upon efforts at the policy and community level to ensure population access to COVID-19 vaccination, a strong health care system response is critical to address vaccine hesitancy. Drawing on the evidence base in social, behavioral, communication, and implementation science, we review, summarize, and encourage use of interpersonal, individual-level, and organizational interventions within clinical organizations to address this critical gap and improve population adoption of COVID-19 vaccination.
Collapse
Affiliation(s)
- Lila J Finney Rutten
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN
| | - Xuan Zhu
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN
| | - Aaron L Leppin
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN
| | - Jennifer L Ridgeway
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN
| | - Melanie D Swift
- Department of Health Sciences Research, Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Joan M Griffin
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN
| | - Jennifer L St Sauver
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Division of Epidemiology, Mayo Clinic, Rochester, MN
| | - Abinash Virk
- Division of Preventive, Occupational, and Aerospace Medicine, Mayo Clinic, Rochester, MN
| | - Robert M Jacobson
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN; Department of Medicine, and Division of Community Pediatric and Adolescent Medicine and Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN.
| |
Collapse
|
19
|
Lott BE, Okusanya BO, Anderson EJ, Kram NA, Rodriguez M, Thomson CA, Rosales C, Ehiri JE. Interventions to increase uptake of Human Papillomavirus (HPV) vaccination in minority populations: A systematic review. Prev Med Rep 2020; 19:101163. [PMID: 32714778 PMCID: PMC7372149 DOI: 10.1016/j.pmedr.2020.101163] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 06/27/2020] [Accepted: 07/04/2020] [Indexed: 12/16/2022] Open
Abstract
Nine studies intervened on vaccination in racial/ethnic and sexual and gender minorities. Education and reminders increased HPV vaccine series initiation and completion. Lack of high-quality, adequately powered studies warrants further investigation.
Minority youth represent a unique population for public health interventions given the social, economic, and cultural barriers they often face in accessing health services. Interventions to increase uptake of Human Papillomavirus (HPV) vaccination in minority youth have the potential to reduce disparities in HPV infection and HPV-related cancers. This systematic review assesses the effectiveness of interventions to increase HPV vaccine uptake, measured as vaccine series initiation and series completion, among adolescents and young adults, aged 9–26 years old, identifying as a racial and ethnic minority or sexual and gender minority (SGM) group in high-income countries. Of the 3013 citations produced by a systematic search of three electronic databases (PubMed, Embase, and Web of Science) in November 2018, nine studies involving 9749 participants were selected for inclusion. All studies were conducted in the United States and were published from 2015 to 2018. Interventions utilized education, vaccine appointment reminders, and negotiated interviewing to increase vaccination. Participants were Black or African American (44.4%), Asian (33.3%), Hispanic or Latinx (22.2%), American Indian or Alaska Native (11.1%), and SGM (22.2%). Studies enrolled parent–child dyads (33.3%), parents alone (11.1%), and youth alone (55.6%). Vaccine series initiation ranged from 11.1% to 84% and series completion ranged from 5.6% to 74.2% post-intervention. Educational and appointment reminder interventions may improve HPV vaccine series initiation and completion in minority youth in the U.S. Given the lack of high quality, adequately powered studies, further research is warranted to identify effective strategies for improving HPV vaccine uptake for minority populations.
Collapse
Affiliation(s)
- Breanne E Lott
- Department of Health Promotion Sciences, Mel and Enid Zukerman College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Babasola O Okusanya
- Department of Health Promotion Sciences, Mel and Enid Zukerman College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Elizabeth J Anderson
- Department of Health Promotion Sciences, Mel and Enid Zukerman College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Nidal A Kram
- Department of Health Promotion Sciences, Mel and Enid Zukerman College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Melina Rodriguez
- Department of Health Promotion Sciences, Mel and Enid Zukerman College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Cynthia A Thomson
- Canyon Ranch Center for Prevention and Health Promotion, Department of Health Promotion Sciences, Mel and Enid Zukerman College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Cecilia Rosales
- Division of Public Health Practice and Translational Research, Mel and Enid Zukerman College of Public Health, University of Arizona, Tucson, AZ, USA
| | - John E Ehiri
- Department of Health Promotion Sciences, Mel and Enid Zukerman College of Public Health, University of Arizona, Tucson, AZ, USA
| |
Collapse
|
20
|
Jacobson RM, St Sauver JL, Griffin JM, MacLaughlin KL, Finney Rutten LJ. How health care providers should address vaccine hesitancy in the clinical setting: Evidence for presumptive language in making a strong recommendation. Hum Vaccin Immunother 2020; 16:2131-2135. [PMID: 32242766 PMCID: PMC7553710 DOI: 10.1080/21645515.2020.1735226] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Vaccine hesitancy occurs throughout the world and can result in poor vaccine uptake and vaccine-preventable disease-outbreaks. Vaccine hesitancy dates back to the days of Edward Jenner and the smallpox vaccine. It persists despite the preponderance of evidence supporting vaccine safety and effectiveness. Studies show even among parents of well-vaccinated children that 15–35% of those parents are vaccine-hesitant. Studies have failed to show the efficacy of educational interventions, and, indeed, a number of studies of educational interventions show a contrarian effect leaving the vaccine-hesitant more entrenched in their views. Still dozens of studies support health care provider recommendation as a major factor in achieving high rates of vaccine uptake. Furthermore, studies find those recommendations perceived as stronger are more effective than those perceived as weaker. What makes for a stronger recommendation? Several observational studies indicate that presumptive, announcement language as contrasted with participatory, conversational language makes for a stronger more effective recommendation. Several trials now demonstrate that health care providers and practices can implement this language and obtain higher vaccination uptake. The authors recommend the practice be adopted as a routine practice in the clinical setting for all vaccinations
Collapse
Affiliation(s)
- Robert M Jacobson
- Department of Pediatric and Adolescent Medicine, Mayo Clinic , Rochester, MN, USA.,Department of Health Sciences Research, Mayo Clinic , Rochester, MN, USA
| | | | - Joan M Griffin
- Department of Health Sciences Research, Mayo Clinic , Rochester, MN, USA
| | | | | |
Collapse
|
21
|
Harris KL, Tay D, Kaiser D, Praag A, Rutkoski H, Dixon BL, Pinzon LM, Winkler JR, Kepka D. The perspectives, barriers, and willingness of Utah dentists to engage in human papillomavirus (HPV) vaccine practices. Hum Vaccin Immunother 2019; 16:436-444. [PMID: 31361179 DOI: 10.1080/21645515.2019.1649550] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Including dental health providers in human papillomavirus (HPV) vaccination could reduce rising rates in HPV-associated oropharyngeal cancer (HPV-OPC). This study assessed Utah dentists' perspectives on providing HPV vaccination education and services in the dental setting. A cross-sectional, 70-item self-administered survey was conducted among a convenience sample of N = 203 practicing Utah dentists. Statistical analyses included Chi Square tests of independence, scaled scores and Cronbach's alpha coefficients. Majority of Utah dentists surveyed perceived that discussing the link between HPV and OPC and recommending the HPV vaccine is within their scope of practice, but not administration of the HPV vaccine. Dentists with >10 minutes of patient education per week were less likely to be concerned about the cultural, social norms or religious ideology of discussing HPV with their patients (p = .024). Rural dentists were more concerned about the safety and liability of the HPV vaccine (p = .011). Good internal consistency was observed survey items regarding barriers and willing to engage in HPV vaccination practices. Dental providers were interested in HPV training and patient education brochures as strategies, but less interested in administering the HPV vaccine. Dental associations support dentists' engagement in HPV education and HPV-OPC prevention. This is the first study in Utah to examine dentists' perspectives on HPV vaccination. Findings have implications for program planning, intervention development, and future research.
Collapse
Affiliation(s)
- Katherine L Harris
- Gyneocologic Oncology, Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - D Tay
- College of Nursing, University of Utah, Salt Lake City, UT, USA
| | - D Kaiser
- Cancer Control and Population Sciences, Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - A Praag
- Cancer Control and Population Sciences, Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - H Rutkoski
- School of Dental Medicine, University of Nevada, Las Vegas, NV, USA
| | - B L Dixon
- School of Dentistry, University of Utah, Salt Lake City, UT, USA
| | - L M Pinzon
- School of Dentistry, University of Utah, Salt Lake City, UT, USA
| | - J R Winkler
- School of Dentistry, University of Utah, Salt Lake City, UT, USA
| | - D Kepka
- College of Nursing, University of Utah, Salt Lake City, UT, USA.,Cancer Control and Population Sciences, Huntsman Cancer Institute, Salt Lake City, UT, USA
| |
Collapse
|
22
|
Katsuta T, Moser CA, Offit PA, Feemster KA. Japanese physicians' attitudes and intentions regarding human papillomavirus vaccine compared with other adolescent vaccines. PAPILLOMAVIRUS RESEARCH 2019; 7:193-200. [PMID: 31051270 PMCID: PMC6520551 DOI: 10.1016/j.pvr.2019.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 04/26/2019] [Accepted: 04/29/2019] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Japan has experienced extremely low human papillomavirus vaccine (HPVV) coverage following the suspension of proactive governmental recommendations in 2013. Several studies have reported that recommendations from physicians increase adolescents' vaccine acceptance. In this survey, we evaluated the attitudes and intentions of Japanese physicians related to adolescent immunizations, particularly HPVV. METHODS We conducted a cross-sectional study using a mailed questionnaire targeting 330 Japanese physicians including 78 pediatricians, 225 internists and 27 obstetricians and gynecologists (OB/GYNs) in Kawasaki City, Japan in 2016. The survey measured physicians' reported frequency of educating adolescents about vaccines as well as their own perceptions and intentions related to adolescent immunizations. RESULTS Valid responses were obtained from 148 (45%) physicians. Though 53% agreed that the HPVV should be recommended, only 21% reported educating about HPVV. The majority of respondents (90%) agreed that they would restart HPVV for adolescents if the government reinstated its recommendation. CONCLUSIONS Although Japanese physicians reported support for adolescent immunizations, they were less likely to recommend or discuss HPVV compared with other adolescent vaccines. Responses indicated this was, at least in part, due to the lack of governmental support for HPVV, indicating that their recommendations would improve with government endorsement of the vaccine.
Collapse
Affiliation(s)
- Tomohiro Katsuta
- Department of Pediatrics, St. Marianna University School of Medicine, Kawasaki, Japan; Vaccine Education Center, Children's Hospital of Philadelphia, Philadelphia, PA, United States. katsuta-7-@marianna-u.ac.jp
| | - Charlotte A Moser
- Vaccine Education Center, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Paul A Offit
- Vaccine Education Center, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Kristen A Feemster
- Vaccine Education Center, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| |
Collapse
|
23
|
Walling EB, Dodd S, Bobenhouse N, Reis EC, Sterkel R, Garbutt J. Implementation of Strategies to Improve Human Papillomavirus Vaccine Coverage: A Provider Survey. Am J Prev Med 2019; 56:74-83. [PMID: 30573149 PMCID: PMC6948017 DOI: 10.1016/j.amepre.2018.07.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 07/24/2018] [Accepted: 07/25/2018] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Human papillomavirus (HPV) vaccine coverage in the U.S. is persistently suboptimal, despite research describing barriers to vaccination and strategies to increase vaccination coverage. The objective was to assess providers' approach to the HPV vaccine and their implementation of strategies to increase HPV vaccination coverage. The hypothesis was that adoption of improvement measures to address underuse of the HPV vaccine has not occurred. METHODS Community pediatric providers from two Midwestern practice-based research networks completed self-administered electronic surveys. Data were collected over 6 months in 2015 and organized and analyzed in 2016. RESULTS There were 100 providers that participated. Despite agreement with national recommendations, some providers delayed their recommendation until the adolescent was older and many reported missed vaccination opportunities. Many providers experienced parental concerns including safety of the HPV vaccine, belief their child was not at risk of HPV infection, and their child's resistance to receiving multiple shots. Providers identified the following as barriers to adherence to Advisory Committee on Immunization Practices guidelines: bad publicity of the HPV vaccine, information about the HPV vaccine on the web, and a lack of a follow-up system for those who delayed HPV vaccine initiation. Approximately half of the participants had implemented strategies to address these barriers beyond offering immunization-only appointments. CONCLUSIONS Participants were aware of barriers to HPV vaccine use, but many had not adopted a systematic approach to increase vaccine coverage. A better understanding of the challenges facing providers to adopting improvement measures and a strategy to address barriers to implementation are needed to improve HPV coverage.
Collapse
Affiliation(s)
- Emily B Walling
- Division of Hematology and Oncology, Department of Pediatrics, Washington University, School of Medicine, St. Louis, Missouri; Department of Pediatrics and Communicable Diseases, Division of Hematology and Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Sherry Dodd
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Neil Bobenhouse
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Evelyn Cohen Reis
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Randy Sterkel
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Jane Garbutt
- Division of General Medical Sciences, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| |
Collapse
|
24
|
Finney Rutten LJ, Radecki Breitkopf C, St Sauver JL, Croghan IT, Jacobson DJ, Wilson PM, Herrin J, Jacobson RM. Evaluating the impact of multilevel evidence-based implementation strategies to enhance provider recommendation on human papillomavirus vaccination rates among an empaneled primary care patient population: a study protocol for a stepped-wedge cluster randomized trial. Implement Sci 2018; 13:96. [PMID: 30001723 PMCID: PMC6043954 DOI: 10.1186/s13012-018-0778-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 06/07/2018] [Indexed: 11/10/2022] Open
Abstract
Background Each year, human papillomavirus (HPV) causes 30,000 cancers in the USA despite the availability of effective and safe vaccines. Uptake of HPV vaccine has been low and lags behind other adolescent vaccines. This protocol describes a multilevel intervention to improve HPV vaccination rates. Methods Using a cluster randomized trial, we will evaluate the independent and combined impact of two evidence-based implementation strategies with innovative enhancements on HPV vaccination rates for female and male patients. The clusters are six primary care sites providing care to pediatric populations. We will use a stepped-wedge cluster randomized design, including process evaluation, to test the hypothesis that compared with the current course of care and a practice-level intervention using reminder-recall interventions coupled with provider-level audit and feedback with education increases HPV vaccination rates in exposed clusters. The factorial design allows us to use a single trial to test these two interventions and to assess each individually and in combination. Our design has four 12-month steps. The first step will be a baseline period; data collected during it will provide a within-practice control group for each cluster. Second, two clusters will be randomly assigned to receive intervention 1 (reminder and recall), and two clusters will be randomly selected to receive intervention 2 (audit and feedback with education). Third, the other two clusters will be randomly allocated to intervention 1 or 2. Clusters initially with intervention 1 will be randomly allocated to 1 + 2 or 1; clusters initially with intervention 2 will be randomly allocated to 1 + 2 or 2. Fourth, all clusters will receive both interventions. To ensure balance of patient numbers across interventions, we will use block randomization at the first step, with the six clusters grouped into three pairs according to volume. Our primary outcome will be vaccination rates. Discussion Results of our clinical trial and process evaluation will provide evidence showing whether practice- and provider-level interventions improve HPV vaccination rates and will offer insight into contextual factors associated with direction and magnitude of trial outcomes. Trial registration ClinicalTrials.gov, NCT03501992, registered April 18, 2018. Electronic supplementary material The online version of this article (10.1186/s13012-018-0778-x) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Lila J Finney Rutten
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA. .,Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
| | | | - Jennifer L St Sauver
- Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Division of Epidemiology, Mayo Clinic, Rochester, MN, USA
| | - Ivana T Croghan
- Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Division of Epidemiology, Mayo Clinic, Rochester, MN, USA.,Nicotine Dependence Center, Mayo Clinic, Rochester, MN, USA
| | - Debra J Jacobson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Patrick M Wilson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | | | - Robert M Jacobson
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA.,Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
25
|
Bonville CA, Domachowske JB, Cibula DA, Suryadevara M. Immunization attitudes and practices among family medicine providers. Hum Vaccin Immunother 2017; 13:2646-2653. [PMID: 29028414 DOI: 10.1080/21645515.2017.1371380] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE To describe immunization attitudes and practices among family medicine providers across New York State. METHODS In this cross-sectional survey study, family medicine providers across New York State completed a questionnaire to assess vaccine beliefs and barriers and immunization practices. STATISTICAL ANALYSIS Descriptive statistical methods were used to define provider characteristics, knowledge and vaccine practices. RESULTS Completed questionnaires from 226 family medicine providers were included for analysis. As a group, 207/218 (95%) of providers who answered the question state they always recommend standard pediatric vaccines. Of the 209 providers who answered both questions, 47 (22%) state they always recommend standard pediatric vaccines but do not always recommend HPV vaccine to eligible 11-12 year-old patients. Only 75% of providers strongly disagreed with the statement 'vaccinating adolescents against HPV increases the likelihood of unprotected sex'. Even though 178/190 (94%) and 164/188 (87%) of surveyed family medicine providers reported recommending that their pregnant patients receive influenza vaccine and Tdap vaccine, respectively, only 134/185 (72%) routinely do so in their office. CONCLUSION Most family medicine providers self-report always recommending standard pediatric vaccines, however only a minority are following ACIP recommendations. Educational sessions to update family medicine providers on ACIP recommendations and address individual provider concerns may improve provider vaccine confidence and uptake of vaccines by their patients.
Collapse
Affiliation(s)
- Cynthia A Bonville
- a Department of Pediatrics , State University of New York, Upstate Medical University , Syracuse , NY , USA
| | - Joseph B Domachowske
- a Department of Pediatrics , State University of New York, Upstate Medical University , Syracuse , NY , USA
| | - Donald A Cibula
- b Department of Public Health and Preventive Medicine , State University of New York, Upstate Medical University , Syracuse , NY , USA
| | - Manika Suryadevara
- a Department of Pediatrics , State University of New York, Upstate Medical University , Syracuse , NY , USA
| |
Collapse
|
26
|
Finney Rutten LJ, St Sauver JL, Beebe TJ, Wilson PM, Jacobson DJ, Fan C, Breitkopf CR, Vadaparampil ST, MacLaughlin KL, Jacobson RM. Association of both consistency and strength of self-reported clinician recommendation for HPV vaccination and HPV vaccine uptake among 11- to 12-year-old children. Vaccine 2017; 35:6122-6128. [PMID: 28958810 DOI: 10.1016/j.vaccine.2017.09.056] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 09/15/2017] [Accepted: 09/18/2017] [Indexed: 02/08/2023]
Abstract
PURPOSE We tested the hypotheses that consistency and strength of clinician recommendation of the human papillomavirus (HPV) vaccination would be associated with vaccine delivery rates. METHODS From October 2015 through January 2016, we conducted a survey of primary care clinicians (n=227) in Southeastern Minnesota to evaluate clinician behaviors regarding HPV vaccination. The survey response rate was 41.0% (51 clinical sites). We used the Rochester Epidemiology Project, a clinical data linkage infrastructure, to ascertain clinical site-level HPV vaccination rates. We examined associations of clinician self-reports of both the consistency and strength of their recommendations for HPV vaccination for patients aged 11-12years (n=14,406) with site-level vaccination rates. RESULTS The majority of clinicians reported consistently (always or usually) recommending the HPV vaccine to females (79.0%) and to males (62.2%); 71.9% of clinicians reported strongly recommending the vaccine to females while 58.6% reported strongly recommending to males. Consistency and strength of recommending the HPV vaccine was significantly higher among those practicing in pediatrics and board certified in pediatrics compared to family medicine. Higher rates of initiation (1 dose) [Incidence Rate Ratio (IRR)=1.05; 95% CI (1.01-1.09)] and completion (3 doses) [IRR=1.08; 95% CI (1.02-1.13)] were observed among clinical sites where, on average, clinicians more frequently reported always or usually recommending the vaccine for females compared to sites where, on average, clinicians reported recommending the vaccine less frequently. Similarly, higher rates of initiation [IRR=1.03; 95% CI (1.00-1.06)] and completion [IRR=1.04; CI (1.00, 1.08)] were observed among sites where clinicians reported strongly recommending the vaccine to females more frequently compared to sites where, on average, clinicians reported strongly recommending the HPV vaccine less frequently; similar associations were observed for male initiation [IRR=1.05; CI (1.02,1.08)] and completion [IRR=1.05; 95% CI (1.01, 1.09)]. CONCLUSIONS Consistency and strength of HPV vaccination recommendation was associated with higher vaccination rates.
Collapse
Affiliation(s)
- Lila J Finney Rutten
- Robert D. and Patricia E. Center for the Science of Health Care Delivery, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA; Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA; Robert D. and Patricia E. Center for the Science of Health Care Delivery, Departments of Health Sciences Research and Pediatric and Adolescent Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA.
| | - Jennifer L St Sauver
- Robert D. and Patricia E. Center for the Science of Health Care Delivery, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA; Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Timothy J Beebe
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Mayo Building A302, 420 Delaware Street SE, Minneapolis, MN 55455, USA.
| | - Patrick M Wilson
- Robert D. and Patricia E. Center for the Science of Health Care Delivery, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA; Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Debra J Jacobson
- Robert D. and Patricia E. Center for the Science of Health Care Delivery, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA; Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Chun Fan
- Robert D. and Patricia E. Center for the Science of Health Care Delivery, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA; Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Carmen Radecki Breitkopf
- Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Susan T Vadaparampil
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA.
| | - Kathy L MacLaughlin
- Department of Family Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA.
| | - Robert M Jacobson
- Robert D. and Patricia E. Center for the Science of Health Care Delivery, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA; Robert D. and Patricia E. Center for the Science of Health Care Delivery, Departments of Health Sciences Research and Pediatric and Adolescent Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA.
| |
Collapse
|
27
|
Kaya A, Altınel N, Karakaya G, Çetinkaya F. Knowledge and attitudes among patients with asthma and parents and physicians towards influenza vaccination. Allergol Immunopathol (Madr) 2017; 45:240-243. [PMID: 27789065 DOI: 10.1016/j.aller.2016.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 08/01/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Influenza is an infectious disease, dangerous for all people, especially for some risk groups such as patients with chronic diseases and health care workers. But most of the people under the risk of influenza, including health care workers are not immunised because of misinformation. In this study, we aimed to determine the knowledge, beliefs and attitudes of patients with allergic rhinitis and asthma and parents of such children related to influenza vaccination. Attitudes and beliefs of physicians treating these patients about influenza vaccination were also investigated. METHODS Two different questionnaires consisting of various items related to influenza vaccine were distributed to physicians and patients and parents of children with asthma and allergic disease. RESULTS The physicians group consisted of 189 physicians from various branches. About one third of physicians from various branches reported that they did not believe the vaccine's effectiveness. Most of the participating physicians did not immunise themselves with influenza vaccination despite the fact that any patient of theirs had died due to influenza infection. Although nearly half of the 183 patients had been vaccinated with influenza vaccine, only 27% of adults and 11.7% of children had been vaccinated annually. CONCLUSIONS Asthmatic patients are not immunised regularly with influenza vaccine due to misperceptions about vaccine effectiveness and fear of adverse effects. Another important reason of this is that most the physicians caring for these patients neither immunise themselves nor recommend the vaccine to their patients.
Collapse
Affiliation(s)
- A Kaya
- Sisli Etfal Education and Research Hospital, Department of Pediatric Immunology and Allergy, Istanbul, Turkey
| | - N Altınel
- Bakırkoy Dr. Sadi Konuk Education and Research Hospital, Department of Pediatric Immunology and Allergy, Istanbul, Turkey
| | - G Karakaya
- Division of Immunology and Allergy, Department of Chest Diseases, School of Medicine, Hacettepe University, Ankara, Turkey
| | - F Çetinkaya
- International Hospital, Yesilkoy, Istanbul, Turkey.
| |
Collapse
|
28
|
Redondo E, Rivero I, Vargas D, Mascarós E, Díaz-Maroto J, Linares M, Valdepérez J, Gil A, Molina J, Jimeno I, Ocaña D, Martinón-Torres F. Vacunación frente a la neumonía adquirida en la comunidad del adulto. Posicionamiento del Grupo de Neumoexpertos en Prevención. Semergen 2016; 42:464-475. [DOI: 10.1016/j.semerg.2016.07.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 07/14/2016] [Indexed: 10/21/2022]
|
29
|
Wilson AR, Hashibe M, Bodson J, Gren LH, Taylor BA, Greenwood J, Jackson BR, She R, Egger MJ, Kepka D. Factors related to HPV vaccine uptake and 3-dose completion among women in a low vaccination region of the USA: an observational study. BMC Womens Health 2016; 16:41. [PMID: 27449775 PMCID: PMC4957275 DOI: 10.1186/s12905-016-0323-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 07/15/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To assess the demographic and attitudinal factors associated with HPV vaccine initiation and completion among 18-26 year old women in Utah. METHOD Between January 2013 and December 2013, we surveyed 325 women from the University of Utah Community Clinics about their HPV vaccine related beliefs and behaviors. Odds ratios (ORs) were estimated from logistic regression models to identify variables related to HPV vaccine initiation and series completion. RESULTS Of the 325 participants, 204 (62.8 %) had initiated the vaccine and 159 (48.9 %) had completed the 3-dose series. The variables associated with HPV vaccine initiation were lower age (OR = 1.18 per year); being unmarried (OR = 3.62); not practicing organized religion (OR = 2.40); knowing how HPV spreads (OR = 6.29); knowing the connection between HPV and cervical cancer (OR = 3.90); a belief in the importance of preventive vaccination (OR = 2.45 per scale unit); strength of doctor recommendation (OR = 1.86 per scale unit); and whether a doctor's recommendation was influential (OR = 1.70 per scale unit). These variables were also significantly associated with HPV vaccine completion. CONCLUSION The implications of these findings may help inform policies and interventions focused on increasing HPV vaccination rates among young women. For example, without this information, programs might focus on HPV awareness; however, the results of this study illustrate that awareness is already high (near saturation) in target populations and other factors, such as strong and consistent physician recommendations, are more pivotal in increasing likelihood of vaccination. Additionally, our findings indicate the need for discussions of risk assessment be tailored to the young adult population.
Collapse
Affiliation(s)
- Andrew R. Wilson
- />University of Utah, College of Nursing, 10 South 2000 East, Room 2200, Salt Lake City, Utah 84112 USA
| | - Mia Hashibe
- />Huntsman Cancer Institute, Cancer Control and Population Sciences, 2000 Circle of Hope, Salt Lake City, Utah 84112 USA
- />University of Utah, Department of Family and Preventive Medicine, University of Utah School of Medicine, 375 Chipeta Way Ste, A Salt Lake City, Utah 84108 USA
| | - Julia Bodson
- />Huntsman Cancer Institute, Cancer Control and Population Sciences, 2000 Circle of Hope, Salt Lake City, Utah 84112 USA
| | - Lisa H. Gren
- />University of Utah, Department of Family and Preventive Medicine, University of Utah School of Medicine, 375 Chipeta Way Ste, A Salt Lake City, Utah 84108 USA
| | - Brooke A. Taylor
- />University of Utah, Department of Family and Preventive Medicine, University of Utah School of Medicine, 375 Chipeta Way Ste, A Salt Lake City, Utah 84108 USA
| | - Jessica Greenwood
- />University of Utah, Department of Family and Preventive Medicine, University of Utah School of Medicine, 375 Chipeta Way Ste, A Salt Lake City, Utah 84108 USA
| | - Brian R. Jackson
- />ARUP Laboratories, 500 Chipeta Way, Salt Lake City, Utah 84108 USA
- />Department of Pathology, University of Utah, 15 North Medical Drive East, Salt Lake City, Utah 84112 USA
| | - Rosemary She
- />University of Southern California, Keck School of Medicine, 1975 Zonal Ave, Los Angeles, California 90033 USA
| | - Marlene J. Egger
- />University of Utah, Department of Family and Preventive Medicine, University of Utah School of Medicine, 375 Chipeta Way Ste, A Salt Lake City, Utah 84108 USA
| | - Deanna Kepka
- />University of Utah, College of Nursing, 10 South 2000 East, Room 2200, Salt Lake City, Utah 84112 USA
- />Huntsman Cancer Institute, Cancer Control and Population Sciences, 2000 Circle of Hope, Salt Lake City, Utah 84112 USA
| |
Collapse
|
30
|
Jacobson RM, Agunwamba AA, St Sauver JL, Finney Rutten LJ. The most effective and promising population health strategies to advance human papillomavirus vaccination. Expert Rev Vaccines 2015; 15:257-69. [PMID: 26559567 DOI: 10.1586/14760584.2016.1116947] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The US is failing to make substantive progress toward improving rates of human papillomavirus vaccine uptake. While the Healthy People 2020 goal for human papillomavirus (HPV) vaccination is 80%, the three-dose completion rate in the US in 2014 for 13- to 17-year-old females is less than 40%, and the rate for males is just above 20%. Experts point to a number of reasons for the poor HPV vaccination rates including parental concerns about safety, necessity, and timing. However, the evidence refuting these concerns is substantial. Efforts focusing on education and communication have not shown promise, but several population health strategies have reminder/recall systems; practice-focused strategies targeting staff, clinicians, and parents; assessment and feedback activities; and school-based HPV vaccination programs.
Collapse
Affiliation(s)
- Robert M Jacobson
- a Department of Pediatric and Adolescent Medicine, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery , Mayo Clinic , Rochester , MN , USA
| | - Amenah A Agunwamba
- b Department of Health Sciences Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery , Mayo Clinic , Rochester , MN , USA
| | - Jennifer L St Sauver
- b Department of Health Sciences Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery , Mayo Clinic , Rochester , MN , USA
| | - Lila J Finney Rutten
- b Department of Health Sciences Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery , Mayo Clinic , Rochester , MN , USA
| |
Collapse
|
31
|
Jackowska J, Bartochowska A, Karlik M, Wichtowski M, Tokarski M, Wierzbicka M. The Knowledge of the Role of Papillomavirus-Related Head and Neck Pathologies among General Practitioners, Otolaryngologists and Trainees. A Survey-Based Study. PLoS One 2015; 10:e0141003. [PMID: 26501885 PMCID: PMC4621019 DOI: 10.1371/journal.pone.0141003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 10/02/2015] [Indexed: 01/05/2023] Open
Abstract
Objectives The aim of the survey was to introduce knowledge of HPV's role in head and neck pathologies to general physicians (GPs), otorhinolaryngologists (ENTs) and newly graduated doctors, as well as to promote HPV-related diseases prevention. Study Design Cross-sectional study. Methods Self-designed questionnaire was sent to 2100 doctors. A total of 404 doctors, including 144 ENTs, 192 GPs and 68 trainees, responded. Results The majority of ENTs (86.8%) had contact with recurrent respiratory papillomatosis (RRP) and oropharyngeal cancers (OPCs) patients; in contrast, the majority of GPs (55.7%) did not (p = 0.00). The knowledge of HPV aetiology of cervical cancer versus OPCs and RRP was statistically higher. 7% of ENTs, 20% of GPs and 10% of trainees had not heard about HPV in oropharyngeal diseases. Women had greater knowledge than men. Both in the group of GPs and ENTs, 100% of respondents had heard about the impact of vaccination on the reduction of cervical cancer incidence. Only 39.11% of respondents had heard about the possibility of using vaccination against HPV in RRP—ENT doctors significantly more often than GPs and trainees (p = 0.00). Only 28.96% of physicians had heard about the potential value of HPV vaccination in preventing OPCs, including 44.44% of ENT doctors, 23.44% of GPs and 11.76% of trainees (p = 0.00). The doctors from district hospitals showed lower level of knowledge compared with clinicians (p = 0.04). Conclusions The different levels of knowledge and awareness of HPV issues highlight the need for targeted awareness strategies in Poland with implementation of HPV testing and vaccination. The information should be accessible especially to those with lower education levels: ENTs from small, provincial wards, GPs from cities of < 200 000 inhabitants and older physicians. The incorporation of HPV issues into the studies curriculum would be fruitful in terms of improving the knowledge of trainees.
Collapse
Affiliation(s)
- Joanna Jackowska
- Department of Otolaryngology, Head and Neck Surgery, University of Medical Sciences, Poznan, Poland
| | - Anna Bartochowska
- Department of Otolaryngology, Head and Neck Surgery, University of Medical Sciences, Poznan, Poland
| | - Michał Karlik
- Department of Phoniatrics and Audiology, University of Medical Sciences, Poznan, Poland
| | - Mateusz Wichtowski
- Oncological Surgery Ward I, Greater Poland Cancer Center, Poznan, Poland
| | - Maciej Tokarski
- Department of Otolaryngology, Head and Neck Surgery, University of Medical Sciences, Poznan, Poland
- * E-mail:
| | - Małgorzata Wierzbicka
- Department of Otolaryngology, Head and Neck Surgery, University of Medical Sciences, Poznan, Poland
| |
Collapse
|
32
|
Vaccine hesitancy among parents of adolescents and its association with vaccine uptake. Vaccine 2015; 33:1748-55. [PMID: 25659278 DOI: 10.1016/j.vaccine.2015.01.068] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 01/21/2015] [Accepted: 01/27/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Addressing parental vaccine hesitancy may increase adolescent vaccination acceptance. However, no validated measure exists to identify parents hesitant toward adolescent vaccines. OBJECTIVE To determine if a modified version of the Parent Attitudes about Childhood Vaccines (PACV) survey, a previously validated tool to identify parental hesitancy toward vaccines in infants, predicts adolescent vaccine uptake at office visits. METHODS We modified the PACV for use in the adolescent setting and distributed it to a convenience sample of parents of adolescents aged 11 to 17 presenting for care at a diverse group of six pediatric practices in Oklahoma and South Carolina. We determined the vaccination status of the parents' adolescents for 3 vaccines (Tetanus-diphtheria-acellular pertussis [Tdap], meningococcal conjugate [MCV4], and human papillomavirus [HPV] vaccines). We used Fisher's exact tests to compare vaccination status with each survey item and with an overall general hesitancy scale that we constructed. RESULTS We analyzed 363 surveys. At the time of the visit, vaccination coverage was 84% for Tdap, 73% for MCV, and 45% for any dose of HPV. Thirty-nine percent of parents expressed concern about vaccine efficacy and 41% expressed concern about side effects. Forty-five percent of parents disagreed with the statement that "teens can get all of the vaccines that are due at a single visit." Two individual items were associated with not receiving a dose of HPV vaccine that was due. The overall modified PACV score failed to predict adolescent vaccine uptake at an office visit. CONCLUSION Several individual items were associated with vaccine uptake. The cumulative modified PACV, a general measure of vaccine hesitancy, was not associated with vaccination status despite illuminating parental hesitancy. We need to better understand vaccine-specific concerns for the adolescent population.
Collapse
|
33
|
Chao C, Preciado M, Slezak J, Xu L. A randomized intervention of reminder letter for human papillomavirus vaccine series completion. J Adolesc Health 2015; 56:85-90. [PMID: 25438965 DOI: 10.1016/j.jadohealth.2014.08.014] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 08/13/2014] [Accepted: 08/15/2014] [Indexed: 11/17/2022]
Abstract
PURPOSE Completion rate for the three-dose series of the human papillomavirus (HPV) vaccine has generally been low. This study evaluated the effectiveness of a reminder letter intervention on HPV vaccine three-dose series completion. METHODS Female members of Kaiser Permanente Southern California Health Plan who received at least one dose, but not more than two doses, of the HPV vaccine by February 13, 2013, and who were between ages 9 and 26 years at the time of first HPV vaccination were included. Eighty percent of these females were randomized to receive the reminder letter, and 20% were randomized to receive standard of care (control). The reminder letters were mailed quarterly to those who had not completed the series. The proportion of series completion at the end of the 12-month evaluation period was compared using chi-square test. RESULTS A total of 9,760 females were included in the intervention group and 2,445 in the control group. HPV vaccine series completion was 56.4% in the intervention group and 46.6% in the control groups (p < .001). The effect of the intervention appeared to be stronger in girls aged 9-17 years compared with young women aged 18-26 years at the first dose and in blacks compared with whites. CONCLUSIONS Reminder letters scheduled quarterly were effective to enhance HPV vaccine series completion among those who initiated the vaccine. However, a large gap in series completion remained despite the intervention. Future studies should address other barriers to series completion, including those at the providers and the health care system level.
Collapse
Affiliation(s)
- Chun Chao
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California.
| | - Melissa Preciado
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Jeff Slezak
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Lanfang Xu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| |
Collapse
|
34
|
Suryadevara M, Bonville CA, Cibula DA, Valente M, Handel A, Domachowse JR, Domachowske JB. Pertussis vaccine for adults: Knowledge, attitudes, and vaccine receipt among adults with children in the household. Vaccine 2014; 32:7000-7004. [DOI: 10.1016/j.vaccine.2014.10.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 10/02/2014] [Accepted: 10/03/2014] [Indexed: 11/16/2022]
|