Allison Kennedy Leslie Rodriguez Maureen Marshall Michelle Basket

Allison Kennedy Leslie Rodriguez Maureen Marshall Michelle Basket
Changing the Conversation: Providers Addressing Parental Hesitancy Using Formative Research with Parents to Inform Development and Distribution of Health Education Provider Resources for Vaccine Conversations with Parents: Health Education Materials from Research to Practice Allison Kennedy Leslie Rodriguez Maureen Marshall Michelle Basket National Center for Immunizations and Respiratory Diseases

Research update

Research with Health Care Professionals
Completed 2008 in-depth interviews with pediatricians and family physicians 2009 survey of pediatricians and family physicians (partnership with U of Colorado) Pilot evaluation of educational materials with WA state health care professionals In-depth interviews (IDIs) to discuss provider resources Ongoing or Planned Field testing of dissemination and use of materials (partnership with American Academy of Pediatrics and American Academy of Family Physicians)

IDIs: Vaccines at Well-Baby Visits
Physicians reported that mothers are most commonly the caregiver that attends well-baby visits with their child. However, some physicians reported seeing more dads in recent years. Some physicians also reported seeing more moms and dads together, especially at the earlier visits. Vaccines are generally administered at the end of the visit. Physicians reported believing they answer parents’ questions about vaccines more often than nurses. However, physicians reported that it is most frequently a nurse or medical assistant who administers the vaccines. Preliminary 5

IDIs: General Findings
Physicians reported that most of their parents follow the recommended schedule. A small subset request to follow an alternate schedule, usually due to concerns about the number of “pokes” or the perceived immune system burden. A very small subset refuse all vaccines. Physicians reported that parents most often refuse the flu and MMR vaccines. Parents most frequently asked questions are about: Thimerosal /mercury; Autism; Side effects; and/or Safety of combination shots Physicians reported that among parents who have concerns about autism, most link it with the MMR vaccine, while a smaller number link autism to thimerosal or all vaccines. Preliminary 6

IDIs: Physician Recommendations to Increase Parental Confidence
Physician Education Physicians should be well-versed in vaccine safety in order to effectively address parents’ concerns. Parent Education Parents need access to sources of accurate information about vaccines in order to address their questions. Move vaccine education upstream Parent education should begin early, ideally at the prenatal visit. Use Mainstream Media Positive messages about vaccines/vaccine safety should be publicized in the media, in order to counter false information. Preliminary 27

Research with Parents Completed Ongoing or Planned
2008, 2009, 2010 HealthStyles mail surveys of parents 2008 and 2009 focus group research with moms 2008 online testing of draft educational materials with moms 2010 national poll of parent vaccine attitudes and behaviors 2010 cognitive interviews and focus groups with moms to test readability of Vaccine Information Statements (VIS) Ongoing or Planned 2011 focus groups and intercept interviews with parents to discuss vaccination barriers and facilitators, and to test message concepts Includes research with high and low acculturation Hispanic parents and with fathers 2011 HealthStyles mail survey of parents 2012 national poll of parent vaccine attitudes and behaviors

Methods: 2010 HealthStyles
Mail survey of U.S. households Response rate=67% (4,198/6,253) Data are weighted to be nationally representative Our analysis was restricted to the 376 respondents with a child 6 years of age or younger Looked at health information attitudes and behaviors, vaccine attitudes, and specific vaccine concerns

2010 HealthStyles: Summary
The majority of parents surveyed are confident in vaccine safety, and either have already vaccinated or plan to fully vaccinate their child 67% of parents were comfortable or very comfortable with the number of vaccines children receive before age two When asked how many shots they were comfortable with their child receiving at one office visit, the most common response was 1-2 shots (46%), followed by 3-4 shots (28%) and “whatever the doctor recommends” (21%); few parents replied “none” or “5 or more” Preliminary

Confidence in Vaccine Safety
Percent of parents of at least one child 6 years of age or younger who reported that they were confident or very confident in the safety of routine childhood vaccines (Source: PN HealthStyles and ConsumerStyles Surveys) Percent 4:3:1:3:3:1 coverage in 2008 was 77.5%--EXCLUDING HIB--among month old children in the US. 4:3:1:3:3:1=≥4 doses of diphtheria, tetanus toxoid, and any acellular pertussis vaccine including diphtheria and tetanus toxoid vaccine or diphtheria, tetanus toxoid, and pertussis vaccine, ≥3 doses of poliovirus vaccine; ≥1 dose of measles, mumps, and rubella vaccine; ≥3 doses of Haemophilus influenzae type b vaccine; ≥3 doses of hepatitis B vaccine; and ≥1 dose of varicella vaccine. ************************************************************************************************* Methods: For each year with available data, analysis was restricted to the sample of parents with one or more children 6 years of age or younger—see below for unweighted sample sizes. Proportions shown in the slide were weighted to be representative of the U.S. population. 2002: HealthStyles (unweighted n=689) 2003: HealthStyles (unweighted n=649) 2005: ConsumerStyles (unweighted n=2,647) 2006: ConsumerStyles (unweighted n=2,304) 2008: HealthStyles (unweighted n=608) 2009: HealthStyles (unweighted n=475) 2010: HealthStyles (unweighted n=376) Year

2010 HealthStyles: Summary
The most common concern reported by parents was a child’s pain from shots This was followed closely by the number of shots given at a single doctor’s visit and in the first two years of life A child’s healthcare provider was cited most often as an important source of vaccine information Most parents reported that their child’s healthcare provider is easy to talk to and that they trust the provider’s vaccine advice Preliminary

Child’s healthcare provider, such as a doctor or nurse (85%)
What are the three most important sources of information that have helped you make decisions about your youngest child’s vaccinations? Child’s healthcare provider, such as a doctor or nurse (85%) Family (46%) American Academy of Pediatrics (28%) CDC (26%) Internet (24%) Preliminary

Which concerns, if any, do you have about childhood vaccines?
2010 Weighted % It is painful for children to receive so many shots during one doctor’s visit. 38 My child getting too many vaccines in one doctor’s visit. 36 Children get too many vaccines in the first two years of life. 34 Vaccines causing fevers in my child. 32 Vaccines may cause learning disabilities (such as autism). 30 Note: The main question was edited in 2009 to help avoid leading respondents. This might account for some of the changes when compared to previous years. Preliminary

Methods: National Poll
March-April 2010 telephone survey of 1,503 parents of children months of age Response rate was 46% Looked at self-reported vaccination behavior, vaccine attitudes, and communication with vaccination providers Data are weighted to be nationally representative of households with children under two years of age

2010 National Poll: Parent-Reported Vaccination Behaviors
75% reported never refusing or delaying a vaccine when it was offered and not planning to do so in the future Includes some who are not up to date 25% reported past or planned delay and/or refusal of one or more recommended vaccines H1N1 was the most common response Analyses are underway to describe and compare these two groups Preliminary

2010 National Poll: Parent Attitudes
Respondents who reported not following the recommended schedule were less likely to Believe that Vaccines are important for keeping children healthy Vaccines are much more important than other things caregivers do to keep children healthy Vaccine-preventable diseases are serious Strongly disagree that vaccines are more dangerous than the diseases they prevent Believe that unvaccinated U.S. children will get vaccine-preventable diseases Report they were very or somewhat comfortable with the recommended number of vaccines in a child’s first 2 years Preliminary

Attitudes, continued Respondents who reported not following the recommended schedule were more likely to report that they personally knew someone else whose child had a reaction to a vaccine that required medical attention and could not be treated at home When asked about whether a child of their own had experienced such a reaction, there was no difference among respondents who were or were not following the recommended schedule Preliminary

Attitudes, continued Respondents who reported not following the recommended schedule Most commonly selected the statement “I tend to have serious concerns about a vaccine and whether my child really needs it” from a list of options that described how they approached childhood vaccines Most commonly selected the statement “They tend not to ask questions about a vaccine before it is given to their child” from a list of options that described how other parents approached childhood vaccines Respondents who reported following the schedule most commonly selected the statement “I tend to ask basic questions before a vaccine is given to my child, like side effects” and that other parents do the same Preliminary

Attitudes, continued Among all respondents, the statement “Conversations with the baby’s health care provider or another professional, such as a nurse, at the same clinic” was cited as the most trusted source for vaccine information Among all respondents, when asked which best describes the vaccination process followed by their baby’s health care provider, the statement “They follow the standard approach for what vaccines to give and when to give them” was most frequently cited 97% for respondents following the recommended schedule 91% for respondents not following the recommended schedule Preliminary

Attitudes, continued Among all respondents, when asked their top question or concern about vaccines, the most common response was “vaccine side effects” followed by “none” and “vaccine safety” 18% of respondents not following the recommended schedule reported having no questions or concerns Overall less than 8% of respondents reported that autism was their top question or concern; there was no difference between respondents who reported following the recommended schedule and those who reported that they were not Preliminary

Translating Research Findings Into Educational Messages and Materials: What have we done and what can you do with all we’ve learned from parents and providers?

Key Drivers to Communication Planning
Vaccine safety issues are a concern for many parents. Risk communication approach is needed to maintain trust. The facts don’t speak for themselves. Personal accounts from peers or health care professionals are persuasive and memorable. There is a spectrum of parental attitudes, beliefs, and behaviors requiring some tailoring and layering of communication practices and materials.

Key Drivers to Communication Planning
Health care professionals play the most important role in addressing parents’ questions and concerns. Recommendations from providers are persuasive. The vast majority of parents are choosing to vaccinate their children.

What does this mean to you when talking to parents about vaccines?
Use language they understand/prefer Start conversations early (i.e., prenatal visits) Use personal stories Encourage other health care professionals to talk to parents Use credible resources to reinforce your messages

What does this mean to you when designing educational materials and interventions?
Educate about vpds Reinforce social norm to vaccinate Refer to other credible sources Use existing resources that have been developed with these findings in mind

CDC/AAP/AAFP Materials “Provider Resources for Vaccine Conversations with Parents”
Primary Target Audience: Health Care Professionals Provide health care professionals information they need to be able to talk to parents about vaccines, vaccine-preventable diseases, and vaccine safety Provide health care professionals with information they can provide to high information seeking parents about vaccines, vaccine-preventable diseases, and vaccine safety

“Talking with Parents about Vaccines for Infants”
During the Office Visit Take time to listen Solicit and welcome questions Keep the conversation going Use a mix of science and personal anecdotes Acknowledge benefits and risks Respect parents’ authority After the Office Visit Document parents’ questions/ concerns Follow up a few days after the visit

Provider-Targeted Materials
Topics of concern/interest to providers and parents Q&A format Summary of key points Date What we heard from providers: -like the bullets, good for high info-seeking parents, use for themselves and staff education, a lot of information, high reading level Some areas were unclear, for example, on the schedule sheet-the flexibility clause-so we changed it Co-branded with AAFP and AAP The science

Parent-Targeted Materials
Quotes from health care professionals Date VPD risks Current stories from families affected by VPDs What we heard in testing: like the stories, but many are too long (we shortened), needs more bullets, like the other format, remove some of the quotes, nice format Vaccine risks and benefits Co-branded with AAFP and AAP References

Other Parent-Targeted Resources

More Parent-Targeted Resources
Well Child Visit Tracker Growth Chart Parent-friendly immunization schedules

Web Research into practice

Destination: CDC.gov/Vaccines
Web Destination for HCPs Immunization schedules in multiple formats Vaccine information statements (VIS) Storage and handling Dosage, contraindications, side effects Educational materials, including Provider Toolkit Web Destination for Parents Recommendations Resources Reassurance

Usability Testing: HCPs
One on one testing of live home page Pediatricians, family medicine doctors, physician’s assistants, and nurses Completed online tasks as well as pre- and post-test interviews Findings Dependent on search function Frustrated with multiple access points Want clearer labels, fewer acronyms Need to see themselves pictured

Applying Research: Web and HPCs
Optimize search engine results Within CDC Vaccines site Bulk up keywords in meta code Offer suggested links or “Best Bets” In the cloud Improve titles Edit descriptions to specific yet promotional

Applying Research: Web and HPCs
Simplify labeling and terms No insult to use plain language Avoid acronyms Simplify navigation Optimize for scanning Use fewer smiling babies

Usability Testing: Parents
One on one testing of prototype Moms and dads With children under age 2 With year olds Performed tasks and completed pre- and post-test questionnaires Findings Gravitated to tailored content Loved the buttons Wanted breadth specific to child’s age Wanted depth specific to age Frustrated with multiple access points

Usability Testing: Parents
Findings, continued Appreciated layers of information Give “just the facts” But also have details and supporting research available Wanted balanced presentation of risks & benefits Said they would not be put off by statistics Internet usage First-time parents more likely to turn to internet for health info Use search engines

Applying Research: Web and Parents
Keep the healthy, smiling kids Tailor content by child’s age Keep buttons; they are intuitive navigation Consolidate age-specific information

Applying Research: Web and Parents
Chunk content, providing detail in layers Just the Facts on vaccine preventable diseases Real-life stories Picture This: graphic presentation of risks & benefits Continue search engine optimization Collaborate with Vaccines.gov

Using Our Findings in Your Web World
Direct application – nothing new, follow tried and true Search engine optimization Button is intuitive Scannable layout Picture is worth a thousand words Don’t reinvent, syndicate When writing Tell stories Chunk text under plain language headings Include statistics Cartoon is copyrighted by Mark Anderson,

Looking Ahead-1 More Provider Resource materials Promotion efforts
Expand partnerships Additional research Field testing of materials with AAP and AAFP 2011 Focus groups with parents 2011 HealthStyles mail survey of parents 2012 National poll of parent vaccine attitudes and behaviors More materials are in development including: Diseases and the vaccines that prevent them Additional vaccine and vaccine safety topics Plain language Spanish language We will have a fact sheet on each of the 14 childhood vaccine-preventable diseases. We will have additional fact sheets, including one on how vaccines work, on the development of the recommended immunization schedule, on the safety of US vaccines. Some, perhaps all, pieces will be translated into Spanish. As the suite of materials grows, so will our promotion efforts and partnership development. Web banners, buttons HTML Print Ads/Insert MedScape commentary Direct mail Content syndication Drop-in Articles We expect that by being able to provide quality materials for our partners to use and by listening and being responsive to their feedback on these materials our collaborations will strengthen and open up additional opportunities for working together. Promotional materials development is a necessary component to marketing and building awareness of Provider Resources. Web buttons and banners to post on Web sites, blasts to send to members, announcement text for publications, printed sample materials, earned and paid media are part of the recommended distribution and marketing mix. Outreach through partner organizations Paid media Earned media Direct engagement Outreach through other organizations The dissemination and promotion activities highlighted here do more than get valuable immunization resources to providers and parents. They can help change the way the conversation about vaccines is taking place which hopefully will lead to more informed decision making about vaccination. Supplementing paid media, earned media will push favorable immunization coverage, increase exposure of Provider Resources, and link target audience members to the CDC Web site. Two audiences will be targeted (1) pediatricians and pediatric nurses and (2) parents. Two matte articles will be tested with healthcare provider audiences this summer for reactions and input. It is anticipated that articles will be finalized and ready to pitch by early Fall. Articles will initially be pitched to partners and then later to additional healthcare professional publications. AAP News article highlighting materials Matte articles for providers Addressing Parental Concerns about Vaccination Top 4 Concerns Parents Have about Vaccines and How to Address Them Matte article for parents How to Make the Most of Your Child’s Vaccine Visit Creative partnerships to get immunization messages to a broader audience Partners are being encouraged to inform their memberships about Provider Resources through membership s, newsletter and/or web placements. To make it as easy as possible on them and to help ensure consistency in messaging, CDC has developed a set of promotional pieces to support Provider Resources promotion efforts. Newsletter text Promotional for memberships Web site announcement Web site buttons PowerPoint presentation 2011 focus groups and intercept interviews with parents to discuss vaccination barriers and facilitators, and to test message concepts Includes research with high and low acculturation Hispanic parents and with fathers

Provider Resources Field Test
Now recruiting pediatricians and family physicians Research: Help us understand how materials can best be used within practices Provide input for future materials Participants will: Incorporate Provider Resources for 6-8 weeks Participate in a 45-minute phone interview To help participate or learn more: Sign up today after the presentation Call Kristina Hartman, AED at 202‑464‑3976 Research will: help us understand how materials can best be used within practices and provide input for future materials development. Now recruiting pediatricians and family physicians Research will help us understand how materials can best be used within practices and provide input for future materials development. Participants will: Incorporate Provider Resources materials in their practices for 4‑6 weeks. Participate in a 45-minute phone interview to discuss their experiences with the materials and related feedback. Have the option of receiving a $150 Visa gift card. To help evaluate these materials or learn more about the field test: (or) Call Kristina Hartman, AED at 202‑464‑3976, by November 12,2010

Looking Ahead - 2 Media toolkit with NPHIC
Parent homepage on cdc.gov/vaccines Public education campaign 2011 Improve communication about vaccines, vaccine–preventable diseases, and vaccine safety The dissemination and promotion activities highlighted here do more than get valuable immunization resources to providers and parents. They can help change the way the conversation about vaccines is taking place which hopefully will lead to more informed decision making about vaccination.

Websites Provider Resources for Vaccine Conversations with Parents
Give Feedback on Provider Resources Health Care Professional Home Page “Get the Picture” Childhood Video Here are all of the various Web sites we mentioned today, where you can access our new resources and give us feedback. We really do hope that you will take the time to provide us with your comments.

Contact Information Allison Kennedy Leslie Rodriguez Maureen Marshall Michelle Basket

Extra slides

Feedback requested Comments will inform future plans Tell Us
We’ve received lots of positive feedback on these resources – Melissa already mentioned feedback received at conference presentations. The anonymous feedback we receive through a web button is similarly positive. We ask what other materials the healthcare professionals would like. One respondent asked for a slide set that could be used when talking about vaccines with a parent audience and we hope to add that tool to the library. One physician requested materials translated – and translation into Spanish is planned. However the physician stated that in his or her practice, the families who refuse vaccines are of Russian descent and so materials were needed in Russian. While we’d love to accommodate, I’m afraid that Russian translation is not in our future plans. Anonymous comments will be taken into consideration as we plan for future promotions and expansion of the library. 51

Methods: In-depth Interviews
Twenty-eight in-person in-depth interviews (IDIs) were conducted across three cities IDIs lasted 60 minutes to allow for deep probing of issues Interviews were led by a trained professional moderator Hepatitis B birth dose knowledge, attitudes, and practices were explored with pediatricians and family medicine physicians Materials from “Provider Resources for Vaccine Conversations” toolkit were tested with pediatricians and family medicine physicians

Interview Breakdown by Specialty/City
Pediatricians Family Medicine Physicians TOTAL Minneapolis, MN 7 3 10 Phoenix, AZ 6 2 8 Oakland, CA 9 1 22 28 Preliminary 4

Methods: 2010 HealthStyles
Mail survey of U.S. households Response rate=67% (4,198/6,253) Data are weighted to be nationally representative Our analysis was restricted to the 376 respondents with a child 6 years of age or younger Looked at health information attitudes and behaviors, vaccine attitudes, and specific vaccine concerns

Demographic Characteristics of HealthStyles Respondents With at Least One Child Age 6 Years or Younger, 2010 2010 Weighted % (n=376) Respondent Age 18-24 years 13 25-34 years 46 35 years and over 41 Respondent Race/Ethnicity White 60 Black 10 Hispanic 24 Other 7 Respondent Education Level High school graduate or less Some college 44 College graduate 20 Post graduate Note: 61.5% of respondents were female. Note: 57.6% of respondents reported annual HH income less than $60,000. Preliminary

Methods: National Poll
March-April 2010 telephone survey of 1,503 parents of children months of age Response rate was 46% Looked at self-reported vaccination behavior, vaccine attitudes, and communication with vaccination providers Data are weighted to be nationally representative of households with children under two years of age

Demographics Mean respondent age = 32 years Most respondents
Were women Were non-Hispanic white Completed some college or higher Lived in households with incomes ranging from $35K - $150K The age distribution of children was 38% 6 through 11 months old 32% 12 through 17 months old 30% 18 through 23 months old

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