Values for preventing influenza-related morbidity and vaccine adverse events in children.

BACKGROUND: Influenza vaccination recently has been recommended for children 6-23 months old, but is not currently recommended for routine use in non-high-risk older children. Information on disease impact, costs, benefits, risks, and community preferences could help guide decisions about which age and risk groups should be vaccinated and strategies for improving coverage. The objective of this study was to measure preferences and willingness-to-pay for changes in health-related quality of life associated with uncomplicated influenza and two rarely-occurring vaccination-related adverse events (anaphylaxis and Guillain-Barré syndrome) in children. METHODS: We conducted telephone interviews with adult members selected at random from a large New England HMO (n = 112). Respondents were given descriptions of four health outcomes: uncomplicated influenza in a hypothetical 1-year-old child of their own, uncomplicated influenza in a hypothetical 14-year-old child of their own, anaphylaxis following vaccination, and Guillain-Barré syndrome. "Uncomplicated influenza" did not require a physician's visit or hospitalization. Preferences (values) for these health outcomes were measured using time-tradeoff and willingness-to-pay questions. Time-tradeoff questions asked the adult to assume they had a child and to consider how much time from the end of their own life they would be willing to surrender to avoid the health outcome in the child. RESULTS: Respondents said they would give a median of zero days of their lives to prevent an episode of uncomplicated influenza in either their (hypothetical) 1-year-old or 14-year-old, 30 days to prevent an episode of vaccination-related anaphylaxis, and 3 years to prevent a vaccination-related case of Guillain-Barré syndrome. Median willingness-to-pay to prevent uncomplicated influenza in a 1-year-old was $175, uncomplicated influenza in a 14-year-old was $100, anaphylaxis $400, and Guillain-Barré syndrome $4000. The median willingness-to-pay for an influenza vaccination for their children with no risk of anaphylaxis or Guillain-Barré syndrome was $50 and $100, respectively. CONCLUSION: Most respondents said they would not be willing to trade any time from their own lives to prevent uncomplicated influenza in a child of their own, and the time traded did not vary by the age of the hypothetical affected child. However, adults did indicate a willingness-to-pay to prevent uncomplicated influenza in children, and that they would give more money to prevent the illness in a 1-year-old than in a 14-year-old. Respondents also indicated a willingness to pay a premium for a vaccine without any risk of severe complications.

Attitudes of healthcare workers in U.S. hospitals regarding smallpox vaccination.

BACKGROUND: The United States is implementing plans to immunize 500,000 hospital-based healthcare workers against smallpox. Vaccination is voluntary, and it is unknown what factors drive vaccine acceptance. This study's aims were to estimate the proportion of workers willing to accept vaccination and to identify factors likely to influence their decisions. METHODS: The survey was conducted among physicians, nurses, and others working primarily in emergency departments or intensive care units at 21 acute-care hospitals in 10 states during the two weeks before the U.S. national immunization program for healthcare workers was announced in December 2002. Of the questionnaires distributed, 1,165 were returned, for a response rate of 81%. The data were analyzed by logistic regression and were adjusted for clustering within hospital and for different number of responses per hospital, using generalized linear mixed models and SAS's NLMIXED procedure. RESULTS: Sixty-one percent of respondents said they would definitely or probably be vaccinated, while 39% were undecided or inclined against it. Fifty-three percent rated the risk of a bioterrorist attack using smallpox in the United States in the next two years as either intermediate or high. Forty-seven percent did not feel well-informed about the risks and benefits of vaccination. Principal concerns were adverse reactions and the risk of transmitting vaccinia. In multivariate analysis, four variables were associated with willingness to be vaccinated: perceived risk of an attack, self-assessed knowledge about smallpox vaccination, self-assessed previous smallpox vaccination status, and gender. CONCLUSIONS: The success of smallpox vaccination efforts will ultimately depend on the relative weight in people's minds of the risk of vaccine adverse events compared with the risk of being exposed to the disease. Although more than half of the respondents thought the likelihood of a bioterrorist smallpox attack was intermediate or high, less than 10% of the group slated for vaccination has actually accepted it at this time. Unless new information about the threat of a smallpox attack becomes available, healthcare workers' perceptions of the vaccine's risks will likely continue to drive their ongoing decisions about smallpox vaccination.

Opinions and practices of clinicians associated with continuation of exclusive breastfeeding

he American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months of life...

Mothers' and clinicians' perspectives on breastfeeding counseling during routine preventive visits

Recent national statistics indicate that, despite increases in the proportion of mothers who initiate breastfeeding, the proportion that continue to breastfeed their infants through 6 months of age remains below the Healthy People 2010 goal of 50%...

Opinions and practices of clinicians associated with continuation of exclusive breastfeeding.

BACKGROUND: The American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months of life. Recent statistics indicate that initiation and maintenance of exclusive breastfeeding are low in the United States. Unfortunately, little information is available on how clinicians and health care organizations can best promote continuation of exclusive breastfeeding. OBJECTIVE: To identify clinicians' opinions and management practices that are associated with continuation of exclusive breastfeeding. METHODS: We conducted a prospective cohort study of low-risk mother-newborn pairs in a large, multispecialty group practice in which the mother was breastfeeding at 4 weeks. Mothers completed telephone interviews at 4 and 12 weeks postpartum, and their data were linked with their obstetric and pediatric clinicians' responses to a cross-sectional mailed survey conducted during the same time period. Obstetric and pediatric clinicians included medical doctors, nurse practitioners, and nurse midwives. Overall response rates were 63% for mothers and 82% for clinicians (54 obstetric and 67 pediatric clinicians). Bivariate and multivariate analyses were conducted to identify the characteristics of clinicians and mothers that predicted exclusive breastfeeding at 12 weeks. RESULTS: Of the 288 mothers who were breastfeeding at 4 weeks and had a complete 12-week interview, 152 (53%) were exclusively breastfeeding their infants at 12 weeks. Mothers who discontinued exclusive breastfeeding were more likely to have experienced problems with their infant latching on or sucking (odds ratio [OR]: 3.8; 95% confidence interval [CI]: 1.5-9.7) or report that a health care provider recommended formula supplementation (OR: 2.3; 95% CI: 1.1-5.0). Clinicians reported limited time during preventive visits to address breastfeeding problems as a very important barrier to promoting breastfeeding. Obstetric providers were least confident in resolving problems with mothers not producing enough breast milk. Pediatric providers were least confident in resolving problems with breast pain or tenderness or cracked or painful nipples. In the final multivariate model, mothers whose pediatric providers recommended formula supplementation if an infant was not gaining enough weight (OR: 3.2; 95% CI: 1.04, 9.7) or who considered their advice to mothers on breastfeeding duration to be not very important (OR: 2.2; 95% CI: 1.2-3.9) were more likely to have discontinued exclusive breastfeeding by 12 weeks postpartum. Black mothers were significantly more likely to discontinue exclusive breastfeeding by 12 weeks. CONCLUSIONS: Clinicians' practices regarding formula supplementation of healthy infants and their opinions about the importance of their breastfeeding advice are associated with the likelihood that mothers will continue exclusive breastfeeding. Policies to enhance clinicians' abilities to address breastfeeding problems within the constraints of busy practices could improve their ability to support exclusive breastfeeding.

Mothers' and clinicians' perspectives on breastfeeding counseling during routine preventive visits.

BACKGROUND: Recent national statistics indicate that, despite increases in the proportion of mothers who initiate breastfeeding, the proportion that continue to breastfeed their infants through 6 months of age remains below the Healthy People 2010 goal of 50%. National professional organizations recommend that clinicians routinely counsel mothers about the benefits of breastfeeding. Little is known, however, about the counseling provided during these visits and how mothers and their clinicians perceive breastfeeding counseling. OBJECTIVES: We sought to describe mothers' and clinicians' perspectives on breastfeeding counseling during routine preventive visits and identify potential gaps in communication about breastfeeding and management practices. METHODS: We conducted a prospective cohort study of low-risk mother-newborn pairs and their clinicians in a large multispecialty group practice. The participating mothers completed telephone interviews at 4 and 12 weeks postpartum, and their data were linked with their obstetric and pediatric clinicians' responses to a cross-sectional mailed survey conducted during the same time period. Overall, response rates were 63% for mothers (n = 429) and 82% for clinicians (obstetric clinicians: n = 54; pediatric clinicians: n = 67). RESULTS: Of the 429 low-risk mother-newborn pairs in the study, 61% were white, 16% were black, 10% were Hispanic, and 8% were Asian, with a mean (SD) age of 32.7 (5.1) years. At 4 weeks postpartum, 319 mothers (74%) were either exclusively or mixed breastfeeding. According to the interviews, few mothers discussed breastfeeding duration with their obstetric clinicians during their prenatal visits (15%) or with their pediatric clinicians during their infants' 2-week preventive visit (24%). Among 164 mothers whose obstetric providers said they usually or always discuss breastfeeding duration during prenatal visits, only 26 (16%) of the mothers reported that the topic was discussed with them (22% agreement; kappa = -.004). Among those mothers whose pediatric clinicians said they usually or always discuss breastfeeding duration during the 2-week preventive visit, only 25% of the mothers reported that the topic was discussed (32% agreement; kappa =.05). Many of the mothers had either returned to work by 12 weeks (29%) or planned to return to work within the next few months (43%). Although nearly all the obstetric (91%) and pediatric (97%) clinicians reported that they usually or always discuss whether a mother plans to continue breastfeeding after returning to work, only approximately half (55%) of the mothers seen by the clinicians reported that the topic was discussed. Overall, few mothers reported discussing with their clinicians specific ways to continue breastfeeding after returning to work. CONCLUSION: Mothers' reports of breastfeeding advice given during routine preventive visits identified several areas in which unintentional communication gaps may occur, including specifics about breastfeeding duration and methods of breastfeeding after returning to work. Developing approaches to enhance communication with mothers during routine preventive visits could improve the support of breastfeeding.