Incidence and Management of Neonatal Pneumothorax in a 10-Hospital Regional Perinatal Network in Switzerland: A Retrospective Observational Study.

OBJECTIVE: Pneumothorax (PTX) is a potentially life-threatening condition that affects neonates, with an incidence of 0.05 to 2%. Its management includes conservative treatment, chest tube (CT) drainage, and needle aspiration (NA). Aims were to evaluate the incidence of PTX in a 10-hospital perinatal network, its clinical characteristics and risk factors, and to compare the different treatment options. STUDY DESIGN: All neonates diagnosed with PTX and hospitalized in the network were included in this retrospective observational trial over a period of 30 months. Primary outcome was the incidence of PTX. Secondary outcomes were the treatment modality, the length of stay (LOS), and the number of chest X-rays. RESULTS: Among the 173 neonates included, the overall incidence of PTX was 0.56 per 100 births with a large range among the hospitals (0.12-1.24). Thirty-nine percent of pneumothoraces were treated conservatively, 41% by CT drainage, 13% by NA, and 7% by combined treatment. Failure rate was higher for NA (37%) than for CT drainage (9%). However, the number of X-rays was lower for patients treated by NA, with a median of 6 (interquartile range [IQR] 4-6.25), than by CT drainage, with a median of 9 (IQR 7-12). LOS was shorter for NA than for CT drainage, with a median of 2 (IQR 1-4.25) and 6 days (IQR 3-15), respectively. Complications, including apnea and urinary retention, occurred in 28% of patients managed with CT drainage, whereas none was observed with NA. CONCLUSION: High variability of PTX incidence was observed among the hospitals within the network, but these values correspond to the literature. NA showed to reduce the number of X-rays, the LOS, and complications compared with CT drainage, but it carries a high failure rate. This study helped provide a new decisional management algorithm to harmonize and improve PTX treatment within our network. KEY POINTS: · Neonatal PTX is a frequent pathology with a high incidence requiring urgent management.. · We report a large variability of PTX incidence between different hospitals of the same network.. · Needle aspiration carries higher failure rate, shorter hospital stay duration without complications reported..

[Integrative medicine: what's new in 2022]. / Médecine intégrative : ce qui a changé en 2022.

To illustrate the news of 2022, we present first a scientific article on mindfulness: a meta-analysis shows both preventive and therapeutic effects for the pediatric population. A second scientific article is summarized: it investigated acupuncture in an obstetrical context, demonstrating its effectiveness on post-caesarean pain and on functional capacity, by improving early mobilization. Hence, these approaches have an increasing level of scientific evidence in these given fields, calling for a clinical implementation. Finally, we offer a practical summary concerning the prescription of cannabis, especially useful following the abolishment of the obligatory FOPH authorization as of August 1, 2022. Nevertheless, we underline that the evidence for cannabinoids being effective remains weak in most indications.

En termes de nouveautés 2022, nous présentons en premier lieu un article scientifique traitant de la pleine conscience : une méta-analyse montre des effets tant préventifs que thérapeutiques pour la population pédiatrique. Le deuxième article scientifique présenté traite de l'acupuncture dans un contexte obstétrical, démontrant son efficacité sur la douleur postcésarienne et sur la capacité fonctionnelle, en améliorant la mobilisation précoce. Ces deux approches bénéficient donc d'un niveau de preuve scientifique croissant appelant à une implantation clinique. Finalement, nous offrons un résumé pratique concernant la prescription de cannabis, tout particulièrement utile suite à la levée de l'obligation d'autorisation de l'OFSP dès le 1er août 2022. Néanmoins, nous soulignons que les preuves restent faibles concernant l'efficacité des cannabinoïdes dans la plupart des indications.

Trust, affect, and choice in parents' vaccination decision-making and health-care provider selection in Switzerland.

This article examines the relationships between biomedicine, complementary and alternative medicine (CAM) and parents' vaccination decision-making in Switzerland. Our empirical evidence sheds light on an understudied phenomenon-parents switching from one doctor to another provider (often one offering CAM services) around issues that arise during vaccination consultations. This is important to understand since CAM is used by 25%-50% of the Swiss population and is integrated into the Swiss health-care system when offered by biomedically trained medical doctors with additional CAM training. Qualitative data gathered from in-depth semi-structured interviews with parents (N = 30) and ethnographic observations of vaccination consultations (N = 16 biomedical consultations, N = 18 CAM consultations) demonstrate how there was not always a clear-cut, direct relationship between (non)vaccination and parents' use of CAM and/or biomedicine. Borrowing from Hirschman (Exit, voice, and loyalty: Responses to decline in firms, organizations, and states, Harvard Univ. Press, 1970), we frame our analysis by using the concepts of exit, voice and loyalty to describe parents' provider selection and vaccination decision-making process, although only four families in the sample described switching solely because of vaccination-related issues. Findings add to vaccine decision-making literature by describing and analysing the underdiscussed provider-switching phenomenon and by demonstrating the importance of parents' experiences of trust, affect and choice in vaccination consultations as they pursue the best health outcomes for their children.

[Pediatric integrative medicine is an integral part of child health care in Switzerland]. / La pédiatrie intégrative fait partie intégrante des soins pédiatriques en Suisse.

Based on evidence and experience, pediatric integrative medicine uses conventional and complementary therapies in an interprofessional approach to optimally support health and development of children and adolescents. Switzerland has a high standard of child health care including complementary medicine. Many pediatricians and family physicians offer an integrative approach to their patients based on additional trainings in complementary medicine, which ensures a full and competent medical care. The Swiss Interest Group for Integrative Pediatrics of the Swiss Society of Pediatrics deals with all questions relating to complementary and integrative medicine in pediatrics including the organization of training events and the coordination of research projects.

Basée sur l'évidence et l'expérience, la pédiatrie intégrative utilise des thérapies conventionnelles et complémentaires dans une approche interprofessionnelle, pour promouvoir de manière optimale le développement et la santé des enfants et adolescents. La Suisse dispose d'un niveau élevé de soins pédiatriques incluant la médecine complémentaire. De nombreux pédiatres et médecins de famille offrent une approche intégrative aux patients, basée sur des formations supplémentaires en médecine complémentaire, ce qui garantit une prise en charge large et compétente. Le Groupe d'intérêt suisse pour la pédiatrie intégrative de la Société suisse de pédiatrie traite de toutes les questions relatives à la médecine complémentaire et l'approche intégrative en pédiatrie, y compris l'organisation des formations et la coordination de la recherche.

[Strategies to reduce antibiotic use with the help of complementary and integrative medicine]. / Stratégies de réduction de l'usage d'antibiotiques à l'aide de la médecine complémentaire et intégrative.

Limiting antibiotic use is urgent due to increasing antibiotic resistance and the long-term implications of a disturbed microbiome. Data on antibiotic use of physicians integrating conventional and complementary medicine show that a significant reduction of antibiotic use in primary care is possible. In the setting of non-complicated infections in out-patient medicine, open dialogue with the patient, recognizing the importance of fever and reducing antipyretic use are general measures that can help reduce patients' concerns, and increase their trust in a well-functioning immune system and a treatment approach without antibiotics. Accumulating evidence suggests that complementary medicine strategies are useful in the management of common infections without antibiotics.

Vu l'augmentation de la résistance aux antibiotiques et les conséquences qu'implique, à long terme, un microbiote perturbé, il est urgent de limiter leur consommation. Les données obtenues chez les médecins intégrant médecines conventionnelle et complémentaire montrent un recours aux antibiotiques diminué dans les soins primaires. Une communication adaptée, la compréhension de l'importance de la fièvre et la diminution de la prise d'antipyrétiques sont autant d'étapes clés pouvant aider les patients à surmonter leurs craintes, à renforcer leur confiance en leur système immunitaire et en un traitement sans antibiotiques en cas d'infections simples. Un nombre croissant d'études démontre ainsi que les outils de la médecine complémentaire peuvent contribuer à la gestion des infections courantes sans antibiotiques.

Antibiotic Use in a Neonatal Intensive Care Unit Practicing Integrative Medicine-A Retrospective Analysis.

Background: Antibiotic use in neonatal intensive care units (NICUs) remains high. Low antibiotic prescribing has been documented among physicians trained in complementary medicine. This study sought to identify if an NICU integrating complementary medicine has low antibiotic prescribing. Methods: We conducted a retrospective analysis at the level-2 NICU of the Filderklinik, an integrative medicine hospital in Southern Germany, to compare antibiotic use locally and internationally; to compare neonates with suspected infection, managed with and without antibiotics; and to describe use and safety of complementary medicinal products. Results: Among 7778 live births, 1086 neonates were hospitalized between 2014 and 2017. Two hundred forty-six were diagnosed with suspected or confirmed infection, their median gestational age was 40.3 weeks (range 29-42), 3.25% had a birthweight <2500 g, 176 were treated with antibiotics for a median duration of 4 days, 6 had culture-proven infection (0.77 per 1000 live births), and 2.26% of live births were started on antibiotics. A total of 866 antibiotic treatment days corresponded to 111 antibiotic days per 1000 live births and 8.8 antibiotic days per 100 hospital days. Neonates managed with antibiotics more often had fever and abnormal laboratory parameters than those managed without. Complementary medicinal products comprising 71 different natural substances were used, no side effect or adverse event were described. A subanalysis using the inclusion criteria of a recent analysis of 13 networks in Europe, North America, and Australia confirmed this cohort to be among the lowest prescribing networks. Conclusions: Antibiotic use was low in this NICU in both local and international comparison, while the disease burden was in the mid-range, confirming an association between integrative medicine practice and low antibiotic prescribing in newborns. Complementary medicinal products were widely used and well tolerated. Clinical Trial Registration number: NCT04893343.

Interest and need for continuing medical education in pediatric complementary and integrative medicine: a cross-sectional survey from Switzerland.

BACKGROUND: Pediatric integrative medicine, combining conventional and complementary medical approaches for children and adolescents, is an integral part of the health care system in Switzerland. However, there is still a lack of complementary and integrative medicine topics in training and continuing educational programs. For the first time on a national level, the 2021 annual conference of the Swiss Society of Pediatrics was entirely dedicated to the topic of integrative medicine. METHODS: Using a cross-sectional online survey, this study investigated congress participants' evaluation and feedback with the aim to assess whether the program had met their objectives and to get empirical data on their attitude, expectations and needs regarding pediatric complementary and integrative medicine. Descriptive methods were used to present the results. RESULTS: Among 632 participants of the conference, 228 completed the evaluation form (response rate 36%). The overall feedback about the congress and the main theme of pediatric integrative medicine was clearly positive. The majority of respondents had achieved their educational objectives including complementary and integrative medicine issues. 82% were motivated to learn more about complementary and integrative medicine and 66% were stimulated to integrate complementary therapies into their professional practice. CONCLUSION: This study from Switzerland confirms the interest in integrative medicine among pediatricians and supports the need for pre- and postgraduate pediatric training on topics related to complementary and integrative medicine. Developing and adapting training and continuing medical education based on evaluations of participant feedback can promote professional development and improve patient care for the benefit of physicians and patients.

Health Care Professionals' Interest in Vaccination Training in Switzerland: A Quantitative Survey.

Objectives: Health care professionals (HCPs) play an important role for patients' vaccination decisions. To counsel patients/clients appropriately, HCPs need current factual knowledge about vaccines and strong communication skills. Methods: We conducted an online survey with physicians, pharmacists, nurses, and midwives in Switzerland (01.11.2020-31.03.2021). We evaluated: 1) interest in vaccination knowledge and counseling training; 2) vaccination recommendation practices; 3) experience with vaccination counseling/administration; 4) comfort level in addressing vaccine hesitancy (VH); 5) perspectives on patient/client VH, delays, and refusals. Results: In total, 1,933 practicing HCPs responded (496 physicians, 226 pharmacists, 607 nurses, 604 midwives). 43% physicians, 31% pharmacists, 15% nurses, and 23% midwives felt comfortable counseling VH patients/clients. 96% physicians, 98% pharmacists, 85% nurses, and 91% midwives were interested in additional vaccination-related training. All professionals mentioned safety, efficacy, and side effects as topics of most interest for additional training. Conclusion: Results demonstrate a high interest among HCPs for additional vaccination-related training. In addition to factual information about vaccination, such training will likely benefit from a communication component, given the low rates of comfort reported by HCPs when counseling VH patients/clients.

Parental and provider vaccine hesitancy and non-timely childhood vaccination in Switzerland.

OBJECTIVE: Although medical providers are a trusted vaccination information source for parents, they do not universally support vaccination. Complementary medicine (CM) providers are particularly likely to hold vaccine hesitant (VH) views, and VH parents often consult with them. Little research compares VH of parents and providers, and if and how each is associated with uptake of recommended childhood vaccines. METHODS: We defined non-timely receipt as recommended vaccines given > 1 month later than officially recommended, based on vaccination records. We administered versions of the Parent Attitudes about Childhood Vaccines (PACV) 5-item survey instrument to 1256 parents and their children's pediatricians (N = 112, 40 CM-oriented, 72 biomedical [not CM-oriented]) to identify moderately (PACV-score 5-6) and highly (PACV-score 7+) hesitant providers/parents. We obtained multivariable adjusted odds ratios to test relationships between parental VH and provider type/VH, and between non-timely receipt of selected childhood vaccines and parental VH and provider type/VH. RESULTS: No biomedical providers were VH, 9 CM providers were moderately VH, and 17 were highly VH. Parents seeing moderately and highly hesitant providers had adjusted odds ratio (AOR) for being VH = 6.6 (95% confidence interval (CI), 3.1-14.0) and AOR = 31.3 (95% CI 16.8-58.3), respectively. Across all vaccine uptake endpoints, children of moderately and highly hesitant parents had 1.9-3.8 and 7.1-12.3 higher odds of non-timely vaccination, and children seeing highly hesitant CM providers had 4.9-9.4 higher odds. Children seeing moderately hesitant CM providers had 3.3 higher odds of non-timely vaccination for the 1st dose of measles and 3.5 higher odds for 1st dose of polio/pertussis/tetanus. CONCLUSION: VH by both parents and providers each is associated with non-timely childhood vaccination. As VH parents are more likely to consult with VH providers, interventions aimed at increasing timely vaccination need to primarily target VH providers and their clients.

Parents' vaccination information seeking, satisfaction with and trust in medical providers in Switzerland: a mixed-methods study.

OBJECTIVES: The aim of this study was to better understand parental trust in and satisfaction with information sources and medical providers regarding decision making about childhood vaccines. SETTING: The study was part of a Swiss national research programme investigating vaccine hesitancy and underimmunisation. PARTICIPANTS: We conducted qualitative interviews with 37 providers and 30 parents, observed 34 vaccination consultations, and then conducted quantitative surveys with 130 providers (both complementary and alternative medicine (CAM) oriented and biomedically oriented) and 1390 parents. MAIN OUTCOME MEASURES: Participants' vaccination information sources used in their decision-making process, parents' trust in and satisfaction with these sources and providers. RESULTS: Based on the Parent Attitudes about Childhood Vaccines scale, we considered 501 parents as vaccine-hesitant (VH) and 889 parents as non-VH. Whereas both groups mentioned providers as the most trusted source of information, VH-parents were less likely to mention paediatricians (N=358 (71%) vs N=755 (85%)) and public health authorities (N=101 (20%) vs N=333 (37%)) than non-VH-parents. VH-parents were more likely to have consulted another provider (N=196 (39%) vs N=173 (19%)) than non-VH-parents, to express less satisfaction with both their primary (N=342 (82%) vs N=586 (91%)) and other providers (N=82 (42%) vs N=142 (82%)) and less trust in their primary (N=368 (88%) vs N=632 (98%)) and other providers (N=108 (55%) vs N=146 (84%)). VH-parents were less likely to be satisfied with their biomedical primary provider than non-VH-parents (100 (69%) vs 467 (91%)). However, when the primary provider was CAM-oriented, there were similar levels of satisfaction among both groups (237 (89%) VH-parents vs 118 (89%) non-VH-parents). All differences were significant (p<0.05). CONCLUSIONS: While the provider remains the main information source, VH parents turn to additional sources and providers, which is likely related to VH parents being rather dissatisfied with and distrusting in obtained information and their provider. ETHICS: The local ethics committee (Ethikkommission Nordwest- und Zentralschweiz, EKNZ; project ID number 2017-00725) approved the study.

Healthcare professional and professional stakeholders' perspectives on vaccine mandates in Switzerland: A mixed-methods study.

BACKGROUND: There currently are no mandatory vaccines in Switzerland. However, Swiss federal legislation allows for vaccination mandates in settings where the risk of transmission to vulnerable groups is high, such as healthcare professionals (HCPs) working with vulnerable patients. Since HCPs are trusted information sources, a priority population for COVID-19 vaccination, and potentially subjected to mandates, we investigated HCP perspectives on mandates. METHODS: A national online survey was administered to HCPs (October 2020-March 2021), including vaccine mandates questions concerning patients (measles) and HCPs (influenza). We qualitatively investigated HCP mandate perspectives through: (1) 34 interviews with HCPs, HCP professional society representatives, and health authorities; (2) a focus group discussion (FGD) with complementary medicine (CM) and biomedical physicians, and Swiss Federal Vaccination Commission members. RESULTS: 1933 participants (496 physicians, 226 pharmacists, 607 nurses, 604 midwives) responded to the survey. Quantitative results show all professional groups preferred shared parent-HCP measles vaccine decisions (65%, 54%, 50%, 48%, respectively; p for trend < 0.001). Midwives (87%) and nurses (70%) preferred individual influenza vaccination decisions for HCPs, while physicians (49%) and pharmacists (44%) preferred shared employee-employer decisions (p for trend < 0.001). Physicians (p < .001) and pharmacists (p < .01) with CM training favored individual influenza vaccination decisions. Qualitative results show general HCP opposition to vaccine mandates, mainly because participants argued how other approaches, such as HCP training and better information, could encourage uptake. Arguments against COVID-19 mandates included insufficiently documented long-term safety/efficacy data. From participants' perspectives, mandated vaccination should be used as a last resort. Some participants expressed fear that with mandates, notably for influenza and COVID-19, some HCPs might leave their jobs. HCPs were unsure what vaccine mandates would concretely look like in practice, particularly regarding sanctions for non-compliance and enforcement. CONCLUSION: In Switzerland, HCPs generally were opposed to vaccination mandates. Clarity and guidance are needed from health authorities to better inform discussions around vaccine mandates.

Vaccine hesitancy and HPV vaccine uptake among male and female youth in Switzerland: a cross-sectional study.

OBJECTIVES: Identifying factors associated with human papillomavirus (HPV) vaccine uptake is essential for designing successful vaccination programmes. We aimed to examine the association between vaccine hesitancy (VH) and HPV vaccine uptake among male and female youth in Switzerland. DESIGN: With a cross-sectional study, an interview-based questionnaire was used to collect information on sociodemographic factors, vaccination records and to measure the prevalence of VH using the Youth Attitudes about Vaccines scale (YAV-5), a modified version of the Parent Attitudes about Childhood Vaccinations survey instrument. SETTING AND PARTICIPANTS: Eligible male and female participants, 15-26 years of age, were recruited through physicians' offices and military enlistment in all three language regions of Switzerland. Of 1001 participants, we included 674 participants with a vaccination record available (415 males and 259 females) in this study. PRIMARY AND SECONDARY OUTCOME MEASURES: The outcome was uptake for HPV vaccine (having received ≥1 dose of HPV vaccine). Covariates were VH, sex, age and other sociodemographics. RESULTS: 151 (58%) female and 64 (15%) male participants received ≥1 dose of HPV vaccine. 81 (31%) female and 92 (22%) male participants were VH (YAV-5-Score >50). The odds for being unvaccinated were higher for VH women than non-VH women, adjusted OR=4.90 (95% CI 2.53 to 9.50), but similar among VH and non-VH men, OR=1.90 (95% CI 0.84 to 4.31). The odds for being unvaccinated were lower for younger men (born on or after 1 July 2002) than older men (born before 1 July 2002), OR=0.34 (95% CI 0.14 to 0.81), but we found no association between age and vaccine uptake for female youth, OR=0.97 (95% CI 0.48 to 1.97). CONCLUSIONS: VH was associated with lower HPV vaccine uptake in female youth but not male youth in our study population in Switzerland. Our findings suggest that issues other than VH contribute to HPV underimmunisation in male youth in Switzerland.

Application of the Parent Attitudes about Childhood Vaccines (PACV) survey in three national languages in Switzerland: Exploratory factor analysis and Mokken scale analysis.

Vaccine hesitancy (VH) is a complex and context-specific phenomenon that is linked to under-immunization and poses challenges to immunization programs. The Parent Attitudes about Childhood Vaccines (PACV) is an instrument developed to measure VH. We translated the PACV into three languages (German, French and Italian) and administered it to 1388 Swiss parents. We used exploratory factor analysis (EFA) to confirm the scale sub-domains, Cronbach's alpha to assess internal consistency reliability, and Mokken scale analysis (MSA), to explore unidimensionality of each language version. We determined to construct validity by linking parental PACV score to children's immunization status for the first dose of measles vaccine. For the 15-item PACV, EFA extracted three sub-domains in German and French and four sub-domains in Italian. Cronbach's alpha was >0.8 across the three languages, and MSA produced a 13-item German, 14-item French, and 11-item Italian PACV. EFA and MSA of the short version PACV extracted a single factor and scale with Cronbach's alpha >0.7 in all three language versions. VH was significantly associated with non-timely receipt of the first dose of measles in all languages (odds ratio of 20.7, 21.3, and 8.3 for German, French, and Italian languages, respectively). The translated and revised PACV-15 versions are valid and reliable instruments for VH measurement. The structure and reliability of the short version of the PACV was as good as the long version. Our results suggest that the PACV can be used to measure parental VH outside the US in the validated languages.

The Youth Attitudes about Vaccines (YAV-5) scale: adapting the parent attitudes about childhood vaccines short scale for use with youth in German, French, and Italian in Switzerland, exploratory factor analysis and mokken scaling analysis.

No validated measures of vaccine hesitancy (VH) for youth vaccination currently exist. We adapted the Parent Attitudes about Childhood Vaccines survey (PACV-15) for use in youth to create the version Youth Attitudes about Vaccines survey (YAV-14 and YAV-5), then translated it into three languages (German, French, and Italian). We administered the YAV-14 to 1,003 youth aged 15-26 years in Switzerland. We used exploratory factor analysis and Mokken scale analysis to explore the psychometric properties, Cronbach's alpha to investigate the reliability for the YAV-14 and the YAV-5, but we only report results of the YAV-5 analysis here. We determined construct validity by logistic regression of the association between youth VH as measured by the YAV-5 and non-receipt of the first human papillomavirus (HPV) vaccine dose. EFA produced a single scale in German and French while two factors were obtained in Italian. All language versions fit the Mokken scale models with medium-scale strength. There was a significant association between VH and HPV vaccine non-receipt for the full sample (odds ratio (OR); 1.93, 95% confidence interval (CI); 1.31-2.85). Language-stratified analyses found a significant association between VH and non-immunization in the German-language sample. Our results demonstrate that the German version of YAV-5 is a valid and reliable scale for identifying vaccine hesitant youth regardless of sex, and the French version is a valid and reliable scale for identifying vaccine hesitant female youth. Further validation is needed for Italian and French-speaking male youth.

Adrenal insufficiency after glucocorticoid withdrawal in children with rheumatic diseases.

AIM: Glucocorticoids (GCs) are often used for the treatment of rheumatic disorders. However, doses are prescribed, which may suppress the hypothalamic-pituitary-adrenal (HPA) axis. After GC withdrawal, recovery of the HPA axis may be delayed putting the patient at risk for adrenal insufficiency. We assessed adrenal function and factors influencing adrenal responsiveness after termination of GC therapy in paediatric patients with rheumatic diseases. METHODS: Nineteen patients aged 2-15 years were followed clinically, and adrenal function was tested by low-dose adrenocorticotropic hormone test 1 month after GC withdrawal. In case of adrenal insufficiency by test, re-assessment was performed after 6 and 18 months. RESULTS: No signs or symptoms of adrenal insufficiency occurred in any of the patients during and after GC withdrawal. Biochemical examination revealed adrenal insufficiency in 32% (6/19) at 4 weeks and in 11% (2/19) at 20 months after GC withdrawal. CONCLUSIONS: In conclusion, current strategies to withdraw GC from paediatric patients with rheumatic diseases are safe. Routine adrenal function testing after GC therapy and withdrawal may not be needed considering the low risk but high number of patients treated with GCs. Nevertheless, awareness of the potential risk and information of patients and their caregivers are crucial to avoid adrenal crisis.

'Problem patients and physicians' failures': What it means for doctors to counsel vaccine hesitant patients in Switzerland.

This article reports on our qualitative inquiry into the meanings biomedically trained doctors in Switzerland attach to treating vaccine hesitant (VH) and underimmunized patients. With support from social science literature on 'good' and 'bad' patients and doctors, we explore how both doctors and patients cross the boundaries of these conceptual categories in situations involving vaccine hesitancy and underimmunization. The doctors we interviewed (N = 20) and observed (N = 16 observations, subsample of 6 doctors from the interview sample) described how they screened, measured, and diagnosed patients' levels of vaccine hesitancy. Our results emphasize the meanings doctors associated with counseling hesitant patients, especially while managing their own professional responsibilities, legitimacy, and reputations among colleagues and patients. Doctors' discourses constructed the figure of 'problem patients,' characterized through their (potential) non-adherence to vaccination recommendations, desire for lengthy consultations and individualized counseling, and dogmatic ideologies running contra to biomedicine. Discussions around the dilemmas faced by doctors in vaccination consultations brings to the fore several key, yet underdiscussed, paradoxes concerning VH, patient-doctor relationships, and the constructs of 'good'/'bad' doctors and patients. These paradoxes revolve around expectations in Western societies for 'good' patients to be autonomous health-information seekers and active participants in clinical encounters, which research shows to be the case for many VH and underimmunizing individuals. However, in the eyes of many vaccination advocates and proponents of biomedical approaches, VH patients become 'bad' patients thru their risk of non-adherence, which has implications for the population at large. In these consultations, doctors find themselves conflicted around the expectations to promote vaccination while, at the same time, being active listeners and good communicators with those who question their biomedical training and legitimacy. Understanding these paradoxes highlights the need to better support HCPs in addressing VH in clinical practice.

Collaborating with Complementary and Alternative Medicine (CAM) Providers When Writing HPV Vaccine Review Articles.

Novel strategies are needed to address vaccine hesitancy (VH), which correlates with complementary and alternative medicine (CAM). In Switzerland, CAM providers play important roles in vaccine counseling of vaccine hesitant (VH) parents, and traditional vaccination messaging tends to overlook CAM provider perspectives. In the setting of a Swiss national research program on VH, our key strategy has been to work together closely with CAM providers. To assess the feasibility of generating educational human papillomavirus (HPV) vaccine materials that would interest VH healthcare providers (HCPs), we invited four CAM providers to co-author two HPV vaccine review articles for general practitioners. We conducted thematic analysis of CAM provider comments to identify patterns that could complement and improve vaccination messaging from CAM perspectives. We identified several themes and generated an inventory of CAM provider messaging recommendations related to language use, presentation of background information, nuanced statements regarding HPV vaccine efficacy and safety, and communication tools that would be important to VH HCPs. Contrary to our initial expectations, and in an inclusive, respectful atmosphere of open dialogue, we were able to productively finalize our manuscripts. In the opinion of the CAM co-authors, the manuscripts effectively considered the communication needs and perspectives of VH HCPs. Engaging with CAM providers appears to be a feasible and innovative avenue for providing vaccine information and designing communication tools aimed at VH healthcare providers.

"We treat humans, not herds!": A qualitative study of complementary and alternative medicine (CAM) providers' individualized approaches to vaccination in Switzerland.

Complementary and alternative medicine (CAM) providers' roles in parents' decision-making about vaccinations for their children have only recently begun receiving research attention, despite studies showing CAM to be used by 25-50% of the population in Western countries. This article examines how CAM practitioners discuss vaccinations with parents in Switzerland, with a focus on childhood vaccinations and human papillomavirus (HPV) vaccinations. We describe how the CAM providers we interviewed (N = 17) and observed during vaccination consultations (N = 18 observations with 5 providers) employed individualized approaches to vaccination. Triangulation of qualitative evidence from interviews and observations allowed us to analyze their discourses and descriptions of experiences (i.e. what they said) and their practices in situ (i.e. what they did). Evidence gathered shows that practitioners framed vaccination decisions as choices at individual and family levels rather than focusing on public health benefits and consequences. They articulated their perspectives in terms of personal clinical experiences and parents' wishes, concerns, and contexts. Such findings challenge recurring narratives depicting CAM providers as categorically anti-vaccination and suggest that approaches to address vaccine hesitancy in clinical practice could benefit from communication and relational approaches similar to those demonstrated by participants in this study. Such approaches include taking time to understand parents' wishes, involving them in vaccination decisions, and taking their concerns seriously.

Acceptance, satisfaction and cost of an integrative anthroposophic program for pediatric respiratory diseases in a Swiss teaching hospital: An implementation report.

BACKGROUND: For the pilot phase of an integrative pediatric program, we defined inpatient treatment algorithms for bronchiolitis, asthma and pneumonia, using medications and nursing techniques from anthroposophic medicine (AM). Parents could choose AM treatment as add-on to conventional care. MATERIAL AND METHODS: To evaluate the 18-month pilot phase, parents of AM users were asked to complete the Client Satisfaction Questionnaire (CSQ-8) and a questionnaire on the AM treatment. Staff feedback was obtained through an open-ended questionnaire. Economic data for project set-up, medications and insurance reimbursements were collected. RESULTS: A total of 351 children with bronchiolitis, asthma and pneumonia were hospitalized. Of these, 137 children (39%) received AM treatment, with use increasing over time. 52 parents completed the questionnaire. Mean CSQ-8 score was 29.77 (95% CI 29.04-30.5) which is high in literature comparison. 96% of parents were mostly or very satisfied with AM; 96% considered AM as somewhat or very helpful for their child; 94% considered they learnt skills to better care for their child. The staff questionnaire revealed positive points about enlarged care offer, closer contact with the child, more relaxed children and greater role for parents; weak points included insufficient knowledge of AM and additional nursing time needed. Cost for staff training and medications were nearly compensated by AM related insurance reimbursements. CONCLUSIONS: Introduction of anthroposophic treatments were well-accepted and led to high parent satisfaction. Additional insurance reimbursements outweighed costs. The program has now been expanded into a center for integrative pediatrics.