Drivers of COVID-19 vaccine hesitancy among women of childbearing age in Victoria, Australia: A descriptive qualitative study

Objective

Women of childbearing age, including pregnant and breastfeeding women, report higher COVID-19 vaccine hesitancy, but reasons for this hesitancy are unknown. We explored factors influencing vaccine decision-making among women of childbearing age in Victoria, Australia to inform strategies to increase COVID-19 vaccine uptake.

Methods

Twenty-four women aged 18-40 years were interviewed July-October 2021. Interview data were analyzed thematically using an inductive, constructivist approach.

Results

Of 24 participants, 14 (57%) were vaccine-hesitant, of whom 10/14 pregnant or breastfeeding. Six key themes were identified: weighing up perceived risks for self and baby; availability of information; change and contradictions; vaccination above everything; practical issues – hurdles of inconvenience. Vaccine-hesitant women’s concerns included safety in pregnancy, breastfeeding and fertility effects. Some participants expressed a loss of trust in healthcare providers following vaccine mandates.

Conclusions

Public health campaigns and communication should be tailored to address specific concerns to increase COVID-19 vaccine uptake and prevent negative COVID-19 outcomes for women of childbearing age. Findings suggest that effective strategies to address hesitancy in this group may include providing robust short- and long-term safety data across fertility, birth outcomes and child development following COVID-19 vaccination. Other supportive strategies may include systemic changes like making childcare available at vaccination points (where practical), and using data linkage infrastructure to track post-vaccination outcomes.

The value of qualitative methods to public health research, policy and practice

This article reviews the role and use of qualitative methods in public health research.'Signs of quality' are introduced to help guide potential authors to publish their qualitative research in public health journals. We conclude that high-quality qualitative research offers insights that quantitative research cannot. It is time for all public health journals to recognise the value of qualitative research and increase the amount that they publish.

Accuracy assessment of NLCD 2011 impervious cover data for the Chesapeake Bay region, USA

The National Land Cover Database (NLCD) contains three eras (2001, 2006, 2011) of percentage urban impervious cover (%IC) at the native pixel size (30 m-×-30 m) of the Landsat Thematic Mapper satellite. These data are potentially valuable to environmental managers and stakeholders because of the utility of %IC as an indicator of watershed and aquatic condition, but lack an accuracy assessment because of the absence of suitable reference data. Recently developed 1 m2 land cover data for the Chesapeake Bay region makes it possible to assess NLCD %IC accuracy for a 262,000 km2 region based on a census rather than a sample of reference data. We report agreement between the two %IC datasets for watersheds and the riparian zones within watersheds and four additional square units. The areas of the six assessment units were 40 ha cell, 433 ha (riparian mean), 2756 ha cell, 5626 ha cell, 8569 ha (watershed mean) and 22,500 ha cell. Mean Absolute Deviation (MAD) and Mean Deviation (MD) were about 1.5% and -1.5%, respectively, for each of the assessment units except for the riparian unit, for which MAD and MD were 0.88 and 0.62, respectively. NLCD reliably reproduced %IC from the 1 m2 data with a small, consistent tendency for underestimation. Results were sensitive to assessment unit choice. The results for the four largest assessment units had very similar regression parameters, R2 values, and bias patterns. Results for the riparian assessment were different from those for the watershed unit and the other three larger units. MAD was about 50% less for the riparian zones than it was for the watersheds, the direction of bias was less consistent, and NLCD %IC was uniformly higher than 1 m2 %IC in urbanized riparian zones. For the smallest unit, bias patterns were more similar to the riparian unit and regression results were more similar to the four larger units. MAD and MD were also sensitive to the amount of urbanization, increasing as NLCD %IC increased. The low overall bias and positive relationship between bias and urbanization suggest that the benefits of obtaining 1 m2 IC data outside of urban areas may not outweigh the costs of obtaining such data.

Evaluation and management of children younger than two years old with apparently minor head trauma: proposed guidelines

OBJECTIVE

In children <2 years old, minor head trauma (HT) is a common injury that can result in skull fracture and intracranial injury (ICI). These injuries can be difficult to detect in this age group; therefore, many authors recommend a low threshold for radiographic imaging. Currently, no clear guidelines exist regarding the evaluation and management of head-injured infants. We sought to develop guidelines for management based on data and expert opinion that would enable clinicians to identify children with complications of HT and reduce unnecessary imaging procedures. METHODS.

EVIDENCE

References addressing pediatric HT were generated from a computerized database (Medline). The articles were reviewed and evidence tables were compiled. EXPERT PANEL: The multidisciplinary panel was comprised of nine experts in pediatric HT.

CONSENSUS PROCESS

A modified Delphi technique was used to develop the guidelines. Before the one meeting, panel members reviewed the evidence and formulated answers to specific clinical questions regarding HT in young children. At the meeting, guidelines were formulated based on data and expert consensus.

RESULTS

A management strategy was developed that categorizes children into 4 subgroups, based on risk of ICI. Children in the high-risk group should undergo a computed tomography (CT) scan. Those in the intermediate risk group with symptoms of possible ICI should either undergo CT scan or observation. Those in the intermediate risk group with some risk for skull fracture or ICI should undergo CT and/or skull radiographs or observation. Those in the low-risk group require no radiographic imaging.

CONCLUSIONS

We have developed a guideline for the evaluation of children <2 years old with minor HT. The effect of these guidelines on clinical outcomes and resource utilization should be evaluated.

Market forces and organizational evolution at freestanding children's hospitals in the United States

OBJECTIVES

To describe market forces that affect freestanding children's hospitals, to describe the development of formal business relationships among these hospitals and pediatricians and other health care delivery organizations, and to explore the impact of such changes on the roles and missions of these hospitals.

METHODS

All freestanding children's hospitals in the United States in 1991 were identified (n = 44). A survey was mailed to the chief executive officer of each hospital. Data were collected for the period of 1991 through 1996. Twenty-nine of the 44 hospitals surveyed responded.

RESULTS

Twenty-seven (93.1%) of the 29 hospitals reported an increase in competition and a more advanced stage of market evolution. Twenty-five hospitals (86.2%) developed at least one type of business relationship with pediatricians or another health care organization. Twenty-one (72.4%) developed a network of pediatricians. Seventeen (58.6%) developed a relationship with an adult-focused health care organization. There were no significant differences in teaching, research, or charity care activities between those respondents that developed a pediatric network and those that did not or between those respondents that integrated with adult-focused health care organization and those that did not.

CONCLUSIONS

Nearly all freestanding children's hospitals developed new business relationships with physicians and other health care organizations. These new relationships were not associated with any significant changes in teaching, research, or charity care.

Incorporating cultural diversity in randomised controlled trials in midwifery

The randomised controlled trial is currently the 'gold standard' that guides health-care practices. The implementation of new models of midwifery care often relies on results from randomised controlled trials. However, many randomised controlled trials exclude women who do not speak English or are designed in such a way that cultural diversity is not facilitated. This can mean that the sample is not representative of the population from which it was drawn or to which it will be applied. Culturally diverse representation can be achieved through a number of strategies. These include utilising health-care interpreters, ensuring materials are translated into common community languages and engaging the local community. These strategies can be used to ensure that the sample in a randomised controlled trial is culturally and linguistically diverse, and representative of the community. We have conducted a randomised controlled trial of a community-based model of midwifery providing continuity of care in a culturally diverse population. A number of issues in the conduct of a trial within a culturally diverse society are discussed in this paper. The trial will be used to illustrate some of the strategies used to ensure that the sample represented the population from which it was drawn.

Birth centre or labour ward? A comparison of the clinical outcomes of low-risk women in a NSW hospital

A number of birth centres were established in New South Wales as a result of the Shearman Report (NSW Health Department 1989). The objective of this study was to compare the obstetric outcomes, primarily caesarean section rates, of low-risk women presenting in spontaneous labour to the birth centre with those attending the hospital's conventional labour ward. The study showed that there was no significant difference in the caesarean section rate between the groups (3.5% in the birth centre and 4.3% in the labour ward). We suggest that the site of birthing does not affect clinical outcomes for low-risk women at this hospital. These results are relevant to contemporary clinical practice as they question the basis upon which birth centres have been popularised, that is, the medicalisation of birth in conventional labour wards increases intervention rates.

An evaluation of an innovative multimedia educational software program for asthma management: report of a randomized, controlled trial

BACKGROUND

Asthma continues to be a substantial cause of morbidity in pediatric populations. New strategies are needed to provide cost-effective educational interventions for children with asthma, particularly those in the inner city.

OBJECTIVE

To assess the effectiveness of a multimedia educational software program about asthma.

SETTING

A hospital-based primary care clinic and an affiliated neighborhood health center.

DESIGN

Randomized, controlled trial.

POPULATION

Children 3 to 12 years old with physician-diagnosed asthma.

INTERVENTION

An interactive educational computer program, Asthma Control, designed to teach children about asthma and its management. Using a graphic display of a child going through simulated daily events, the game emphasizes: 1) monitoring; 2) allergen identification; 3) use of medications; 4) use of health services; and 5) maintenance of normal activity. Control group participants reviewed printed educational materials with a research assistant.

OUTCOMES

Acute health care use (emergency department and outpatient) was the primary outcome. Secondary outcome measures included maternal report of asthma symptom severity, child functional status and school absences, satisfaction with care, and parental and child knowledge of asthma.

RESULTS

A total of 137 families were enrolled in the study (76 intervention, 61 control). Both intervention and control groups showed substantial improvement in all outcomes during the 12-month follow-up period. Aside from improvement in knowledge after use of the computer program, no differences were demonstrated between the 2 groups in primary or secondary outcome measures. Children reported enjoyment of program use.

CONCLUSIONS

This trial of an educational software program found that it did not produce greater improvement than occurred with review of traditional written materials. Because both groups showed substantial improvement over baseline, computer-based education may be more cost-effective. Alternatively, improvements in illness severity over time may overshadow the effects of such interventions. Rigorous comprehensive evaluations such as this are necessary to assess new interventions intended to improve management and outcomes of asthma.

Social disparities in the use of diagnostic tests for children with gastroenteritis

OBJECTIVE

To determine whether patient demographic characteristics affect the use of diagnostic tests for the evaluation of children with acute gastroenteritis by emergency department (ED) physicians.

DESIGN

Retrospective chart review.

SETTING

Emergency department of a tertiary care pediatric hospital.

SAMPLE

All patients seen in the emergency department over a six-month period with a discharge diagnosis of acute gastroenteritis (GE) as identified through a computerized patient log (n = 503).

MEASURES AND ANALYSIS

Sociodemographic characteristics ("race" and insurance) were obtained from computerized hospital data. The number of tests ordered was identified from the medical records, as were indicators of illness severity. We utilized multivariate logistic regression using the generalized estimating equations (GEE) model to account for repeated visits and adjust for potential confounding.

RESULTS

Hispanic children were less likely to undergo more than two tests [OR.53 (95% CI.31,.92)] or have an X-ray done [OR.31 (95% CI 0.15, 0.67)], after adjustment for age and disease characteristics. Self-pay patients were less likely to have a test performed [OR.53 (95% CI.3,.96)].

CONCLUSIONS

Some patient social characteristics remain associated with differing patterns of use of diagnostic tests for a common pediatric condition. Although this study provides no information on patient outcome, health providers should strive to reduce differences in care based on patient social and economic factors as distinct from characteristics of the patient's condition or medical need.

Physical growth, infant nutrition, breastfeeding, and general nutrition

A constant in the practice of general pediatrics is an emphasis on infant nutrition and monitoring of growth. These topics are the focus of this issue's "Office pediatrics" section. Much of the new research and publication concerning nutrition in childhood in the past year continues to focus on breastfeeding-its short-term and long-term benefits and strategies to increase the number of women who successfully nurse their infants. The documentation of breastfeeding's benefits is becoming increasingly strong, even in developed countries such as the United States. At the same time, the many weaknesses in the health care system's support of this important health-promoting behavior continue to be documented. Separate from breastfeeding per se, additional articles examining the state of nutrition among children in the United States show that despite our relative affluence, malnutrition remains prevalent. The poor and the chronically ill appear particularly vulnerable to inadequate nutrition and should remain a focus of our efforts at nutritional monitoring and support.

Variations in pediatric pneumonia and bronchitis/asthma admission rates. Is appropriateness a factor?

OBJECTIVE

To explore through a pilot study the relationship between appropriateness (medical necessity) and variations in pediatric hospital admission rates across several communities in the Boston (Mass) area for two common pediatric conditions with extremely variable admission rates: pneumonia and bronchitis/asthma.

DESIGN

We identified five communities in the greater Boston area with high, average, and below-average ratios of observed to expected admissions for the study conditions. Diagnosis-specific, criteria-based utilization review instruments were developed by community-based pediatricians and applied by trained nurse reviewers to medical records. ADMISSIONS STUDIED: All admissions for pneumonia (diagnosis related group [DRG] 91) and bronchitis/asthma (DRG 98) of study area residents younger than 18 years to participating hospitals during fiscal year 1986.

OUTCOME MEASURES

For each area, we calculated age-adjusted admission rates, age-adjusted observed to expected ratios, and rates of inappropriate admissions. We tested the hypothesis that admission rates and inappropriateness rates were directly related.

RESULTS

We deemed 9.4% of pneumonia admissions and 4.4% of bronchitis/asthma admissions inappropriate. Rates of inappropriate admissions were not significantly associated with admission rates in this local pilot study for either study condition at P < .05. However, in one community both rates were high for both conditions. Feedback of findings to the key local hospital there resulted in sharp decreases in admission rates for DRGs 91 and 98 in subsequent years.

CONCLUSIONS

Our results suggest that higher pediatric admission rates may not be associated with higher rates of inappropriateness. Further research is needed, with a larger number of communities, to differentiate practice patterns more precisely and explore patient and family preferences.

Hospital-based continuous quality improvement: a realistic appraisal

OBJECTIVE

To evaluate the impact of a continuous quality improvement (CQI) multidisciplinary team process on emergency department admission times.

DESIGN

Prospective observational intervention study.

SETTING

A 349-bed tertiary care, university-affiliated, pediatric teaching hospital.

RESULTS

The time from triage to departure from the emergency department (T1-T3) was reduced by 71 minutes, and the time from the decision to admit to departure from the emergency department (T2-T3) by 38 minutes following the planned interventions. There was no correlation between admission times and hospital inpatient census, number of emergency department admissions on a given day, or work shift. Medical patients were transferred to the wards more slowly than patients admitted by the general surgery service and several specialty surgical services once the decision to admit had been reached. No major adverse clinical outcomes could be attributed to expedited admissions. Physicians and nurses in the emergency department expressed improved satisfaction with the admissions process, while houseofficers on the wards were less satisfied. Parental satisfaction with the speed of admissions remained suboptimal. Additional potential problems with the application of CQI principles in an academic setting were identified.

CONCLUSIONS

Although CQI is a promising approach to certain quality problems, a number of issues remain to be explored before full-scale implementation in academic centers can be endorsed.

Prepaid versus traditional Medicaid plans: lack of effect on pregnancy outcomes and prenatal care

Enrollment of Medicaid recipients into capitated, case-managed systems has been advocated as a method of controlling cost. We studied prenatal care and birth outcomes for women and children enrolled in Aid to Families with Dependent Children (AFDC) in two capitated programs in Santa Barbara, California and Jackson County, Missouri (Prepaid), compared with similar but fee-for-service comparison medical communities in Ventura County, California and St. Louis, Missouri (FFS). At the sites of care, 2,336 inpatient and 823 prenatal care records were abstracted. Women at all sites received fewer than the recommended number of prenatal visits. At no site did more than 40 percent of women receive prenatal care in the first trimester of pregnancy. Mean birth weight and proportion of children of low birth weight (less than 2,500 grams) were similar between the demonstration and comparison counties. Complications of pregnancy and cesarean section rates were also similar between demonstration and comparison counties. This study did not demonstrate a decreased quality of care provided to enrollees in capitated, case-managed Medicaid programs compared with fee-for-service. Basic prenatal care was provided only to some members of this population, regardless of the type of physician payment.

Clinical aspects of acute rheumatic fever

We review the epidemiology and clinical features of recent outbreaks of acute rheumatic fever. The history of this disorder as well as current management practices are also discussed.

Prepaid versus traditional Medicaid plans: effects on preventive health care

Prepaid, case managed systems have been proposed as a method of controlling costs in Medicaid populations. We investigated the utilization of preventive services in two prepaid Medicaid Competition Demonstration programs in Santa Barbara County, Calif., and Jackson County, Mo. (containing the city of Kansas City). Care in the demonstration sites was compared with care given in similar counties functioning under a traditional fee-for-service Medicaid system--Ventura County, Calif., and St Louis, Mo. We tested the hypothesis that preventive care would be less in the capitated demonstrations. 2735 Children's and 3389 adult's charts were abstracted for care received during the calendar year 1985, after the prepaid demonstration had been in place for more than 1 year. No significant differences were found between the demonstration and comparison counties in the proportion of children with complete DPT or OPV immunizations at 1 year of age, with 56% complete in both California counties and 69 and 65% complete in Jackson County and St Louis, respectively. Regression analysis demonstrated a slight, but statistically significant trend towards more immunizations in the demonstration counties. Pap smear use in women of 15-44 years of age was little different in the California counties, but significantly greater in the Jackson County demonstration in Missouri (64 vs 45%). Physician breast examinations were somewhat more likely to occur in the prepaid, case managed demonstration counties. Capitated, case managed systems for the AFDC Medicaid population appear to result in no diminution of preventive services. Substantial problems exist in this, as in other poor populations, in childhood immunizations.

Categorization of etiology of failure to thrive

To develop predictors of organic vs nonorganic causes of failure to thrive, we performed a retrospective chart analysis of 82 hospitalized children. We evaluated predictors by using decision analysis. We estimated potential cost reduction that would have resulted from early categorization of these patients. Twenty-one cases had organic causes, 34 had nonorganic causes, and 19 had both organic and nonorganic causes. Physical examination proved to be a sensitive indicator of an organic component. The composite psychosocial and clinical history, together with the physical examination, accurately predicted the final category. The use of laboratory tests was primarily for confirmation. The use of these factors to identify purely nonorganic growth failure and an evaluation of such cases in an intermediate care facility could save almost $8-- per patient. In-depth psychosocial evaluation is important in all cases of failure to thrive.