Sometimes Your Heart Says 'I Don't Know': Insights From Parents of Undervaccinated Children.

STUDY OBJECTIVE: To explore drivers of suboptimal vaccination rates by understanding why parents without strong antivaccine beliefs do not fully vaccinate their children. METHODS: Four focus groups were conducted in Washington state with 41 parents of children aged 24 to 48 months who delayed, declined, or missed some but not all vaccines. During the focus groups, parents were asked about reasons their child was undervaccinated, information that might address their concerns, and additional support they needed. Transcripts were analyzed using template analysis with deductive and inductive codes. RESULTS: Focus groups identified multiple reasons for parents deciding to delay or decline vaccines for their children, including issues of individualism and control. The groups emphasized the impact of personal circumstances, such as changes in insurance, on whether children were vaccinated. Our data also shed light on the reasons that parents do vaccinate their children, including school vaccination requirements, negative experiences with vaccine-preventable diseases, and a family tradition of vaccinating. Focus group participants offered suggestions for improving vaccine communication with parents such as having more parent/patient-friendly vaccine information, providing forums to discuss their concerns, and offering vaccination information in advance of well-child appointments. CONCLUSIONS: To achieve the full benefit of vaccines on individual and community health, we need better ways to address vaccine hesitancy and decrease barriers. We suggest that many hesitant parents would benefit from more dialog with health care providers about vaccines, more approachable educational materials, and enforcement of existing policies requiring vaccines in schools and childcare facilities.

Nature and Children's Health: A Systematic Review.

CONTEXT: Daily outdoor play is encouraged by the American Academy of Pediatrics. Existing evidence is unclear on the independent effect of nature exposures on child health. OBJECTIVE: We systematically evaluated evidence regarding the relationship between nature contact and children's health. DATA SOURCES: The database search was conducted by using PubMed, Cumulative Index to Nursing and Allied Health Literature, PsychInfo, ERIC, Scopus, and Web of Science in February 2021. STUDY SELECTION: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. In all searches, the first element included nature terms; the second included child health outcome terms. DATA EXTRACTION: Of the 10 940 studies identified, 296 were included. Study quality and risk of bias were assessed. RESULTS: The strongest evidence for type of nature exposure was residential green space studies (n = 147, 50%). The strongest evidence for the beneficial health effects of nature was for physical activity (n = 108, 32%) and cognitive, behavioral, or mental health (n = 85, 25%). Physical activity was objectively measured in 55% of studies, and 41% of the cognitive, behavioral, or mental health studies were experimental in design. LIMITATIONS: Types of nature exposures and health outcomes and behaviors were heterogenous. Risk of selection bias was moderate to high for all studies. Most studies were cross-sectional (n = 204, 69%), limiting our ability to assess causality. CONCLUSIONS: Current literature supports a positive relationship between nature contact and children's health, especially for physical activity and mental health, both public health priorities. The evidence supports pediatricians in advocating for equitable nature contact for children in places where they live, play, and learn.

Achieving an Optimal Childhood Vaccine Policy.

Policies to remove parents' ability to opt-out from school immunization requirements on the basis of religious or personal beliefs (ie, nonmedical exemptions) may be a useful strategy to increase immunization rates and prevent outbreaks of vaccine-preventable disease. However, there is uncertainty about the effectiveness of this strategy and the range of possible outcomes. We advocate for a more deliberative process through which a broad range of outcomes is scrutinized and the balance of values underlying the policy decision to eliminate nonmedical exemptions is clearly articulated. We identify 3 outcomes that require particular consideration before policies to eliminate nonmedical exemptions are implemented widely and outline a process for making the values underlying such policies more explicit.

Longitudinal Trends in Vaccine Hesitancy in a Cohort of Mothers Surveyed in Washington State, 2013-2015.

Parents who refuse or delay vaccines because of vaccine hesitancy place children at increased risk for vaccine-preventable disease. How parental vaccine hesitancy changes as their children age is not known. In 2015, we conducted a follow-up survey of 237 mothers enrolled in a 2-arm clinic-level cluster randomized trial (n = 488) in Washington State that was completed in 2013. We surveyed mothers at their baby's birth, age 6 months, and age 24 months using a validated measure of vaccine hesitancy. Both mean hesitancy scores (mean 4.1-point reduction; 95% CI, 2.5-5.6; P = .01) and the proportion of mothers who were vaccine hesitant (9.7% at baseline vs 5.9% at 24 months; P = .01) decreased significantly from child's birth to age 24 months. Changes from baseline were similar for first-time mothers and experienced mothers. Individual item analysis suggested that the decrease may have been driven by increases in maternal confidence about the safety and efficacy of vaccines. Our results suggest that hesitancy is a dynamic measure that may peak around childbirth and may remit as experience with vaccines accumulates.

Children and Adolescents Unvaccinated Against Measles: Geographic Clustering, Parents' Beliefs, and Missed Opportunities.

OBJECTIVE: We evaluated the extent to which children and adolescents were not vaccinated against measles ("unvaccinated"), clustering within U.S. counties, and factors associated with unvaccination, including parents' vaccine-related beliefs and missed opportunities. METHODS: We analyzed data from the 2010-2013 National Immunization Survey (NIS) and NIS-Teen Survey of households with 19- to 35-month-old children and 13- to 17-year-old adolescents, respectively. We used provider-reported vaccination histories to assess measles vaccination status. RESULTS: In 2013, 7.5% of children and 4.5% of adolescents were unvaccinated against measles. Four-fifths (80.0%) of unvaccinated children lived in counties containing 41.9% of the nation's children, and 80.0% of unvaccinated adolescents lived in counties containing 30.4% of the nation's adolescents. Multivariable statistical analyses found that 74.6% of children who were unvaccinated against measles missed being vaccinated for reasons other than parents' negative vaccine-related beliefs, and 89.6% could be deemed as having at least one missed opportunity for being vaccinated against measles because they were administered at least one dose of other recommended vaccines after 12 months of age. Among adolescents, multivariable analyses found that only demographic factors, not vaccine-related parental beliefs, were independently associated with being unvaccinated. CONCLUSIONS: Reasons other than negative vaccine-related beliefs, including missed opportunities, accounted for the vast majority of unvaccinated children and adolescents.

Physician Communication Training and Parental Vaccine Hesitancy: A Randomized Trial.

BACKGROUND AND OBJECTIVES: Physicians have a major influence on parental vaccine decisions. We tested a physician-targeted communication intervention designed to (1) reduce vaccine hesitancy in mothers of infants seen by trained physicians and (2) increase physician confidence in communicating about vaccines. METHODS: We conducted a community-based, clinic-level, 2-arm cluster randomized trial in Washington State. Intervention clinics received physician-targeted communications training. We enrolled mothers of healthy newborns from these clinics at the hospital of birth. Mothers and physicians were surveyed at baseline and 6 months. The primary outcome was maternal vaccine hesitancy measured by Parental Attitudes on Childhood Vaccines score; secondary outcome was physician self-efficacy in communicating with parents by using 3 vaccine communication domains. RESULTS: We enrolled 56 clinics and 347 mothers. We conducted intervention trainings at 30 clinics, reaching 67% of eligible physicians; 26 clinics were randomized to the control group. Maternal vaccine hesitancy at baseline and follow-up changed from 9.8% to 7.5% in the intervention group and 12.6% to 8.0% in the control group. At baseline, groups were similar on all variables except maternal race and ethnicity. The intervention had no detectable effect on maternal vaccine hesitancy (adjusted odds ratio 1.22, 95% confidence interval 0.47-2.68). At follow-up, physician self-efficacy in communicating with parents was not significantly different between intervention and control groups. CONCLUSIONS: This physician-targeted communication intervention did not reduce maternal vaccine hesitancy or improve physician self-efficacy. Research is needed to identify physician communication strategies effective at reducing parental vaccine hesitancy in the primary care setting.

Rethinking vaccine policy making in an era of vaccine hesitancy: time to rebuild, not remodel?

Recently in this journal, David Ropeik argued for imposing additional burdens upon individuals who refused vaccines for themselves or for their children. Specifically, Ropeik advocated for policies that would decrease the ease of claiming vaccine exemptions and restricting unvaccinated children participation in social activities. We argue that, in order to derive the optimal societal benefit from modern vaccinology in an era of vaccine hesitancy, we need to consider doing more than conventional remodeling of current policies. We may need to fundamentally redesign and rebuild.

Association of vaccine-related attitudes and beliefs between parents and health care providers.

OBJECTIVES: Health care providers influence parental vaccination decisions. Over 90% of parents report receiving vaccine information from their child's health care provider. The majority of parents of vaccinated children and children exempt from school immunization requirements report their child's primary provider is a good source for vaccine information. The role of health care providers in influencing parents who refuse vaccines has not been fully explored. The objective of the study was to determine the association between vaccine-related attitudes and beliefs of health care providers and parents. METHODS: We surveyed parents and primary care providers of vaccinated and unvaccinated school age children in four states in 2002-2003 and 2005. We measured key immunization beliefs including perceived risks and benefits of vaccination. Odds ratios for associations between parental and provider responses were calculated using logistic regression. RESULTS: Surveys were completed by 1367 parents (56.1% response rate) and 551 providers (84.3% response rate). Parents with high confidence in vaccine safety were more likely to have providers with similar beliefs, however viewpoints regarding disease susceptibility and severity and vaccine efficacy were not associated. Parents whose providers believed that children get more immunizations than are good for them had 4.6 higher odds of holding that same belief compared to parents whose providers did not have that belief. CONCLUSIONS: The beliefs of children's health care providers and parents, including those regarding vaccine safety, are similar. Provider beliefs may contribute to parental decisions to accept, delay or forgo vaccinations. Parents may selectively choose providers who have similar beliefs to their own.

Are Recent Medical Graduates More Skeptical of Vaccines?

Rates of delay and refusal of recommended childhood vaccines are increasing in many U.S. communities. Children's health care providers have a strong influence on parents' knowledge, attitudes, and beliefs about vaccines. Provider attitudes towards immunizations vary and affect their immunization advocacy. One factor that may contribute to this variability is their familiarity with vaccine-preventable diseases and their sequelae. The purpose of this study was to investigate the association of health care provider year of graduation with vaccines and vaccine-preventable disease beliefs. We conducted a cross sectional survey in 2005 of primary care providers identified by parents of children whose children were fully vaccinated or exempt from one or more school immunization requirements. We examined the association of provider graduation cohort (5 years) with beliefs on immunization, disease susceptibility, disease severity, vaccine safety, and vaccine efficacy. Surveys were completed by 551 providers (84.3% response rate). More recent health care provider graduates had 15% decreased odds of believing vaccines are efficacious compared to graduates from a previous 5 year period; had lower odds of believing that many commonly used childhood vaccines were safe; and 3.7% of recent graduates believed that immunizations do more harm than good. Recent health care provider graduates have a perception of the risk-benefit balance of immunization, which differs from that of their older counterparts. This change has the potential to be reflected in their immunization advocacy and affect parental attitudes.

Washington State pediatricians' attitudes toward alternative childhood immunization schedules.

OBJECTIVE: To determine the frequency of parents' requests for alternative childhood immunization schedules (ACISs) and pediatricians' comfort with and willingness to use ACISs. METHODS: Washington State primary care pediatricians were asked to complete an Internet-based survey on ACISs. The main outcome measures were the frequency of parents' requests for ACISs, pediatricians' comfort with their use, and pediatricians' willingness to use ACISs for individual vaccines. In addition, respondents were asked to characterize their practices and to provide demographic information. RESULTS: Of the 311 respondents (response rate: 65%), 209 met inclusion criteria and were included in analyses. Overall, 77% of eligible respondents reported that parents sometimes or frequently requested ACISs, and 61% were comfortable using an ACIS if requested by a parent. Pediatricians were least willing to consider using ACISs for diphtheria-tetanus toxoids-acellular pertussis vaccine, Haemophilus influenzae type b vaccine, and pneumococcal conjugate vaccine. Pediatricians who practiced in a neighborhood or community clinic were less comfortable using ACISs than were those in a 1- or 2-physician practice (odds ratio: 0.10). CONCLUSIONS: Washington State pediatricians are regularly being asked to use ACISs, and most of them are comfortable using them if requested. Pediatricians are least willing to delay H influenzae type b vaccine, diphtheria-tetanus toxoids-acellular pertussis vaccine, and pneumococcal conjugate vaccine, which suggests prioritization of immunizations that protect against potentially devastating bacterial infections of infancy and early childhood.

Parental delay or refusal of vaccine doses, childhood vaccination coverage at 24 months of age, and the Health Belief Model.

OBJECTIVE: We evaluated the association between parents' beliefs about vaccines, their decision to delay or refuse vaccines for their children, and vaccination coverage of children at aged 24 months. METHODS: We used data from 11,206 parents of children aged 24-35 months at the time of the 2009 National Immunization Survey interview and determined their vaccination status at aged 24 months. Data included parents' reports of delay and/or refusal of vaccine doses, psychosocial factors suggested by the Health Belief Model, and provider-reported up-to-date vaccination status. RESULTS: In 2009, approximately 60.2% of parents with children aged 24-35 months neither delayed nor refused vaccines, 25.8% only delayed, 8.2% only refused, and 5.8% both delayed and refused vaccines. Compared with parents who neither delayed nor refused vaccines, parents who delayed and refused vaccines were significantly less likely to believe that vaccines are necessary to protect the health of children (70.1% vs. 96.2%), that their child might get a disease if they aren't vaccinated (71.0% vs. 90.0%), and that vaccines are safe (50.4% vs. 84.9%). Children of parents who delayed and refused also had significantly lower vaccination coverage for nine of the 10 recommended childhood vaccines including diphtheria-tetanus-acellular pertussis (65.3% vs. 85.2%), polio (76.9% vs. 93.8%), and measles-mumps-rubella (68.4% vs. 92.5%). After adjusting for sociodemographic differences, we found that parents who were less likely to agree that vaccines are necessary to protect the health of children, to believe that their child might get a disease if they aren't vaccinated, or to believe that vaccines are safe had significantly lower coverage for all 10 childhood vaccines. CONCLUSIONS: Parents who delayed and refused vaccine doses were more likely to have vaccine safety concerns and perceive fewer benefits associated with vaccines. Guidelines published by the American Academy of Pediatrics may assist providers in responding to parents who may delay or refuse vaccines.