Christopher Morfaw

Impact of a physician recommendation and parental immunization attitudes on receipt or intention to receive adolescent vaccines

Four vaccines are recommended by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices for adolescents. Parental attitudes may play a key role in vaccination uptake in this age group. In 2011, we conducted a cross-sectional survey among parents of adolescents in one county in Georgia to identify parental attitudes toward adolescent vaccination, reasons for vaccine acceptance or refusal, and impact of a physician recommendation for vaccination. Physician recommendation was reported as one of the top reasons for receipt or intent to receive any of the vaccines. Physician recommendation of any of the four vaccines was associated with receipt of Tdap (p < 0.001), MCV4 (p < 0.001), and HPV (p = 0.03) and intent to receive Tdap (p = 0.05), MCV4 (p = 0.005), and HPV (p = 0.05). Compared with parents who did not intend to have their adolescent vaccinated with any of the vaccines, parents who did intend reported higher perceived susceptibility (3.12 vs. 2.63, p = 0.03) and severity of disease (3.89 vs. 3.70, p = 0.02) and higher perceived benefit of vaccination (8.48 vs. 7.74, p = 0.02). These findings suggest that future vaccination efforts geared toward parents may benefit from addressing the advantages of vaccination and enhancing social norms. Physicians can play a key role by providing information on the benefits of adolescent vaccination.

Seasonal and 2009 H1N1 influenza vaccine uptake, predictors of vaccination, and self-reported barriers to vaccination among secondary school teachers and staff.

Objective: Teachers, like healthcare workers, may be a strategic target for influenza immunization programs. Influenza vaccination is critical to protect both teachers and the students they come into contact with. This study assessed factors associated with seasonal and H1N1 influenza vaccine uptake among middle- and high-school teachers. Methods: Participants were recruited from two counties in rural Georgia. Data were collected from surveys in September 2009 and May 2010. Multivariate logistic regression was used to assess the association between teachers’ attitudes toward seasonal and H1N1 influenza vaccination and vaccine uptake. Results: Seventy-eight percent of teachers who planned to receive seasonal influenza vaccine and 36% of those who planned to receive H1N1 influenza vaccine at baseline reported that they did so. Seasonal vaccine uptake was significantly associated with perceived severity (odds ratio [OR] 1.57, P=0.05) and self-efficacy (OR 4.46, P=0.006). H1N1 vaccine uptake was associated with perceived barriers (OR 0.7, P=0.014) and social norms (OR 1.39, P=0.05). The number one reason for both seasonal and H1N1 influenza vaccine uptake was to avoid getting seasonal/H1N1 influenza disease. The number one reason for seasonal influenza vaccine refusal was a concern it would make them sick and for H1N1 influenza vaccine refusal was concern about vaccine side effects. Conclusions: There is a strong association between the intention to be vaccinated against influenza (seasonal or 2009 H1N1) and actual vaccination uptake. Understanding and addressing factors associated with teachers’ influenza vaccine uptake may enhance future influenza immunization efforts.

Multicomponent Interventions to Enhance Influenza Vaccine Delivery to Adolescents

OBJECTIVE: To compare school- versus provider-based approaches to improving influenza vaccination coverage among adolescents in rural Georgia. METHODS: We used a nonrandomized, 3-armed design: (1) a middle- and high school-based influenza vaccination intervention in 1 county; (2) a provider-based influenza vaccination intervention in a second county; and (3) a standard-of-care condition in a third county. Interventions also included distribution of an educational brochure, school presentations, and community-based outreach to enhance vaccine knowledge and awareness among adolescents and their parents. RESULTS: During the 2008–2009 influenza season, 70 (19%) of 370 students were vaccinated in the school-based county and 110 (15%) of 736 students were vaccinated in the provider-based county, compared with 71 (8%) of 889 students in the standard-of-care county (risk ratio [RR]school: 2.4 [95% confidence interval (CI): 1.7–3.2]; RRprovider: 1.9 [95% CI: 1.4–2.5]). During 2009–2010, seasonal influenza vaccination coverage was 114 (30.4%) of 375 of students in the school-based county, 122 (16.9%) of 663 of students in the provider-based county, and 131 (15.2%) of 861 students in the standard-of-care county (RRschool: 2.3 [95% CI: 1.9–2.9]; RRprovider: 1.2 [95% CI: 0.97–1.5]). CONCLUSIONS: Special efforts to promote influenza vaccination among rural, predominantly black students were associated with increased vaccination coverage. The school-based influenza vaccination intervention was associated with the highest levels of vaccination coverage. This study revealed the efficacy of school-based influenza education to improve vaccination rates among adolescents.

Development, theoretical framework, and evaluation of a parent and teacher-delivered intervention on adolescent vaccination.

The Advisory Committee on Immunization Practices recommended immunization schedule for adolescents includes three vaccines (tetanus, diphtheria, and acellular pertussis [Tdap]; human papillomavirus [HPV] vaccine; and meningococcal conjugate vaccine [MCV4]) and an annual influenza vaccination. Given the increasing number of recommended vaccines for adolescents and health and economic costs associated with nonvaccination, it is imperative that effective strategies for increasing vaccination rates among adolescents are developed. This article describes the development, theoretical framework, and initial first-year evaluation of an intervention designed to promote vaccine acceptance among a middle and high school–based sample of adolescents and their parents in eastern Georgia. Adolescents, parents, and teachers were active participants in the development of the intervention. The intervention, which consisted of a brochure for parents and a teacher-delivered curriculum for adolescents, was guided by constructs from the health belief model and theory of reasoned action. Evaluation results indicated that our intervention development methods were successful in creating a brochure that met cultural relevance and the literacy needs of parents. We also demonstrated an increase in student knowledge of and positive attitudes toward vaccines. To our knowledge, this study is the first to extensively engage middle and high school students, parents, and teachers in the design and implementation of key theory-based educational components of a school-based, teacher-delivered adolescent vaccination intervention.

Human papillomavirus vaccination among adolescents in Georgia

Human papillomavirus (HPV) vaccination coverage for adolescent females and males remains low in the United States. We conducted a 3-arm randomized controlled trial (RCT) conducted in middle and high schools in eastern Georgia from 2011–2013 to determine the effect of 2 educational interventions used to increase adolescent vaccination coverage for the 4 recommended adolescent vaccines: Tdap, MCV4, HPV and influenza. As part of this RCT, this article focuses on: 1) describing initiation and completion of HPV vaccine series among a diverse population of male and female adolescents; 2) assessing parental attitudes toward HPV vaccine; and 3) examining correlates of HPV vaccine series initiation and completion. Parental attitude score was the strongest predictor of HPV vaccine initiation among adolescents (adjusted odds ratio (aOR): 2.08; 95% confidence interval (CI): 1.80, 2.39). Other correlates that significantly predicted HPV series initiation were gender, study year, and intervention arm. Parental attitudes remained a significant predictor of receipt of 3 doses of HPV vaccine along with gender, race, school type and insurance type. This study demonstrates that positive parental attitudes are important predictors of HPV vaccination and critical to increasing coverage rates. Our findings suggest that more research is needed to understand how parental attitudes are developed and evolve over time.

Preexisting Chronic Health Conditions and Health Insurance Status Associated With Vaccine Receipt Among Adolescents

PURPOSE Four vaccines are routinely recommended for adolescents: tetanus, diphtheria, and acellular pertussis (Tdap); human papillomavirus (HPV); meningococcal-conjugate (MCV4); and a yearly seasonal influenza vaccine. Vaccination promotion and outreach approaches may need to be tailored to certain populations, such as those with chronic health conditions or without health insurance. METHODS In a controlled trial among middle and high school students in Georgia, 11 schools were randomized to one of three arms: no intervention, parent education brochure, or parent education brochure plus a student curriculum on the four recommended vaccines. Parents in all arms were surveyed regarding their adolescents vaccine receipt, chronic health conditions, and health insurance status. RESULTS Of the 686 parents, most (91%) reported their adolescent had received at least one of the four vaccines: Tdap (82%), MCV4 (59%), current influenza vaccine (53%) and HPV (48%). Twenty-three percent of parents reported that their adolescent had asthma. Most parents reported that their adolescents insurance was Medicaid (60%) or private insurance (34%), and 6% reported no insurance. More adolescents with a chronic health condition received any adolescent vaccine than adolescents without a chronic health condition (p < .0001). Among those with no insurance, fewer had received any adolescent vaccine than those with Medicaid or private insurance (p < .0001). CONCLUSIONS The federal Vaccines for Children program offers recommended vaccines free to eligible children (including those without health insurance). Our findings suggest that parents may not be aware of this program or eligibility for it, thus revealing a need for education or other fixes.

Recommendations for Structure and Content for a School-Based Adolescent Immunization Curriculum

Despite high utilization of childhood vaccinations, adolescent immunization coverage rates lag behind recommended coverage levels. The four vaccines recommended for adolescents ages 11 to 18 years are tetanus, diphtheria, and pertussis vaccine; human papillomavirus vaccine; meningococcal conjugate vaccine; and an annual influenza vaccine. The Healthy People 2020 goal is 80% coverage for each recommended immunization, but coverage rates in Georgia among adolescents fall below those goals for all but the tetanus, diphtheria, and pertussis vaccine. We developed a multicomponent intervention that included a school-based, teacher-delivered educational curriculum to increase adolescent vaccination coverage rates in Richmond County, Georgia. We facilitated focus group discussions with middle- and high school science teachers who delivered the immunization curriculum in two consecutive school years. The objective of the focus group was to understand teachers’ perspectives about the curriculum impact and to synthesize recommendations for optimal dissemination of the curriculum content, structure, and packaging. Teachers provided recommendations for curriculum fit within existing classes, timing of delivery, and dosage of delivery and recommended creating a flexible tool kit, such as a downloadable online package. Teachers also recommended increasing emphasis on disease transmission and symptoms to keep students engaged. These findings can be applied to the development of an online, cost-effective tool kit geared toward teaching adolescents about the immune system and adolescent vaccinations.