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1.  Does the relative importance of MMR vaccine concerns differ by degree of parental vaccine hesitancy? 
Background: There has been a rise in the number of vaccine-hesitant parents (VHPs) in the US, many of whom express reservations about administering the MMR vaccine to their children. We studied the relative importance of attitudinal barriers to MMR vaccination among VHPs with differing levels of MMR vaccine-hesitancy.
Methods: We performed a cross-sectional exploratory analysis of a parental survey that assessed common vaccination barriers among MMR vaccine-hesitant parents in Michigan. The outcome of interest was parental MMR vaccination intention, measured on an 11-point scale, with higher numbers corresponding to greater intent. The relative importance of identified barriers to MMR vaccination was assessed across levels of vaccine hesitancy. Exploratory factor analysis was performed to identify underlying attitudinal constructs and assess if these constructs’ importance varied depending on the degree of parental vaccine hesitancy.
Results: Our study population included 79 Michigan parents who initially screened positive for MMR vaccine-hesitancy. Within this sample, 47% of parents were unsure about their vaccination intentions and 20% expressed negative intentions, while a third (33%) of parents had positive vaccination intentions when further questioned. After grouping the barriers in our study into four underlying factors, parents with negative vaccination intentions had statistically significant higher factor score for the factor “risks versus benefits” and a statistically significant lower mean score for “vaccine importance,” compared with parents with unsure or positive intentions.
Conclusions: In this exploratory study we found that vaccine-specific concerns have varying salience for parents based on their vaccination intention. Thus, future educational programs likely should tailor messages based on the degree of vaccine hesitancy expressed in their target populations in order to improve their overall effectiveness.
PMCID: PMC3859768  PMID: 23032161
measles; mumps; rubella; vaccine hesitancy; vaccination barriers; vaccination intention
2.  Development of a survey to identify vaccine-hesitant parents 
Human Vaccines  2011;7(4):419-425.
To develop a survey to accurately assess parental vaccine hesitancy.
The initial survey contained 17 items in four content domains: (1) immunization behavior; (2) beliefs about vaccine safety and efficacy; (3) attitudes about vaccine mandates and exemptions; and (4) trust. Focus group data yielded an additional 10 survey items. Expert review of the survey resulted in the deletion of nine of 27 items and revisions to 11 of the remaining 18 survey items. Parent pretesting resulted in the deletion of one item, the addition of one item, the revision of four items, and formatting changes to enhance usability. The final survey contains 18 items in the original four content domains.
An iterative process was used to develop the survey. First, we reviewed previous studies and surveys on parental health beliefs regarding vaccination to develop content domains and draft initial survey items. Focus groups of parents and pediatricians generated additional themes and survey items. Six immunization experts reviewed the items in the resulting draft survey and ranked them on a 1–5 scale for significance in identifying vaccine-hesitant parents (5 indicative of a highly significant item). The lowest third of ranked items were dropped. The revised survey was pretested with 25 parents to assess face validity, usability and item understandability.
The Parent Attitudes about Childhood Vaccines survey was constructed using qualitative methodology to identify vaccine-hesitant parents and has content and face validity. Further psychometric testing is needed.
PMCID: PMC3360071  PMID: 21389777
pediatrics; vaccination; public health practice; preventive health services; questionnaires
3.  A semi-qualitative study of attitudes to vaccinating adolescents against human papillomavirus without parental consent 
BMC Public Health  2007;7:20.
The first vaccine to prevent human papillomavirus (HPV) and cervical cancer has been licensed, and in future, vaccination may be routinely offered to 10–14 year old girls. HPV is a sexually transmitted virus and some parents may refuse consent for vaccination. Under-16s in the UK have a right to confidential sexual health care without parental consent. We investigated parents' views on making available HPV vaccination to adolescent minors at sexual health clinics without parental consent.
This was a semi-qualitative analysis of views of parents of 11–12 year old school children collected as part of a population-based survey of parental attitudes to HPV vaccination in Manchester. Parents were firstly asked if they agreed that a well-informed child should be able to request vaccination at a sexual health clinic without parental consent, and secondly, to provide a reason for this answer. Ethical perspectives on adolescent autonomy provided the framework for descriptive analysis.
307 parents answered the question, and of these, 244 (80%) explained their views. Parents with views consistent with support for adolescent autonomy (n = 99) wanted to encourage responsible behaviour, protect children from ill-informed or bigoted parents, and respected confidentiality and individual rights. In contrast, 97 parents insisted on being involved in decision-making. They emphasised adult responsibility for a child's health and guidance, erosion of parental rights, and respect for cultural and moral values. Other parents (n = 48) wanted clearer legal definitions governing parental rights and responsibilities or hoped for joint decision-making. Parents resistant to adolescent autonomy would be less likely to consent to future HPV vaccination, (67%) than parents supporting this principle (89%; p < 0.001).
In the UK, the principle of adolescent autonomy is recognised and logically should include the right to HPV vaccination, but this may concern parents who would otherwise approve vaccination.
PMCID: PMC1804267  PMID: 17291343
4.  HPV vaccination among ethnic minorities in the UK: knowledge, acceptability and attitudes 
British Journal of Cancer  2011;105(4):486-492.
Human papillomavirus (HPV) vaccination offers a unique opportunity for the primary prevention of cervical cancer. Studies suggest that knowledge and attitudes about the vaccine are likely to influence uptake. One limitation of most studies assessing HPV vaccine knowledge, attitudes and acceptability is their under representation of ethnic minorities. It is important to ensure that our understanding of HPV knowledge and attitudes include all ethnic groups in the UK. This article reviews research that has considered knowledge, acceptability and attitudes about HPV and the HPV vaccine among ethnic minorities in the UK.
Articles in Medline, CINAHL and PsycINFO (January 2000–March 2010) were searched.
A total of 17 UK-based papers examined knowledge, attitudes or acceptability related to HPV vaccination in the ‘lay' population (parents, adolescents or the general population as opposed to health professionals) and reported findings by ethnicity.
Findings seem to suggest lower awareness of HPV and lower acceptability of the vaccination, which could be important if they are reflected in uptake. More research is needed with ethnic minority groups, particularly in the context of the vaccination programme.
PMCID: PMC3170970  PMID: 21829204
review; ethnic; vaccination; cervical cancer; knowledge
5.  Parental attitudes toward multiple poliovirus injections following a provider recommendation. 
Public Health Reports  2001;116(4):282-288.
OBJECTIVES: Changes to the polio vaccination schedule, first to a sequential inactivated poliovirus/oral poliovirus (IPV/OPV) schedule in 1996 and most recently to an all-IPV schedule, require infants to receive additional injections. Some surveys show parental hesitation concerning extra injections, whereas others show that parents prefer multiple simultaneous injections over extra immunization visits. This study describes parental behavior and attitudes about the poliovirus vaccine recommendations and additional injections at the 2- and 4-month immunization visits. METHODS: Beginning July 1, 1996, providers in eight public health clinics in Cobb and Douglas Counties, Georgia, informed parents of polio vaccination options and recommended the IPV/OPV sequential schedule. A cross-sectional clinic exit survey was conducted from July 15, 1996, to January 31, 1997, with parents whose infants (younger than 6 months) were eligible for a first poliovirus vaccination. RESULTS: Of approximately 405 eligible infants, parents of 293 infants were approached for an interview, and 227 agreed to participate. Of those 227 participants, 210 (92%) parents chose IPV for their infant and 17 (8%) chose OPV. Of greatest concern to most parents was vaccine-associated paralytic polio (VAPP) (155, or 68.3%); the next greatest concern was an extra injection (22, or 9.7%). These parental concerns were unrelated to the number of injections the infant actually received. CONCLUSIONS: After receiving information on polio vaccination options and a provider recommendation, parents overwhelmingly chose IPV over OPV. Concern about VAPP was more common than objection to an extra injection. The additional injection that results from using IPV for an infant's first poliovirus vaccination appears to be acceptable to most parents.
PMCID: PMC1497352  PMID: 12037256
6.  Predicting HPV Vaccine Intentions of College-Age Males: An Examination of Parents and Son’s Perceptions 
To examine male students and their parents’ human papillomavirus (HPV) vaccine communication in relation to males’ willingness to discuss the vaccine with their healthcare provider and likelihood being vaccinated.
Dyads (n=111) of students and parents.
Participants completed a HPV vaccine survey based on the risk perception attitude framework in 2009.
Male’s perceived susceptibility for HPV and self-efficacy to talk to their provider were directly related to their intention to discuss the HPV vaccine, and their intention was directly related to their likelihood of being vaccinated. Parents’ perceived self-efficacy to talk to their son and response-efficacy of the vaccine were directly related to their intention to talk to their son; however, parents’ intention was not related to the likelihood of their son being vaccinated.
College males may benefit from HPV vaccine educational programs that include communication skills training to discuss the HPV vaccine with their parents.
PMCID: PMC3412301  PMID: 22857137
7.  The informed consent in Southern Italy does not adequately inform parents about infant vaccination 
BMC Public Health  2014;14:211.
Vaccination centres in the Campania Region, southern Italy, vaccinate children with a hexavalent vaccine that contains the mandatory vaccines diphtheria, tetanus, poliomyelitis, and viral Hepatitis B. This vaccine also includes two non-mandatory vaccines, pertussis and Haemophilus influenzae type B. Information about these optional vaccines should be communicated to the parents, and informed consent should be obtained from parents before vaccination. We explored whether informed consent was delivered to the parents, whether they signed the consent form, and whether they read and acquired the information about the vaccination that their child would receive.
Childhood immunisations are provided at specific public health vaccination centres, "Unità Operative Materno-infantili’s" (UOMIs). We selected four UOMI from the Campania Region where we interviewed 1039 parents bringing their children for the 1st, 2nd, or 3rd doses of hexavalent vaccine. The consent forms were collected from the four vaccination centres and were analysed with respect to clarity and completeness.
Most of the respondents (89.5%) were mothers between 20 and 39 years of age (80.4% vs 59.6% of the fathers), they were married (87.2% vs 93.5% of the fathers), and only one-half of them were employed (50.2% vs 92.6% of the fathers). The informed consent form was received from 58.1% of the parents and signed by 52.8%, but read by 35.0% of them. Only 1.5% of parents knew which vaccines were mandatory, and 25.0% of them believed that the entire hexavalent vaccine was mandatory. When we asked the parents which non-mandatory vaccinations were administered to their children, only 0.5% indicated the Haemophilus influenzae type B and none indicated the pertussis vaccine. Thirty-six per cent of the parents replied that their child had not received any non-mandatory vaccines. No parents were informed by the operators that their children would receive non-mandatory vaccines.
In our study, consent procedures did not allow parents to acquire correct information about vaccine options for their children. Furthermore, not one health care provider informed parents that their child was receiving non-mandatory vaccines. The informed consent process and the individual health care providers did not properly inform parents about the vaccines administered to their children.
PMCID: PMC3948334  PMID: 24580773
Information; Informed consent; Infant vaccination
8.  A Population-Based Evaluation of a Publicly Funded, School-Based HPV Vaccine Program in British Columbia, Canada: Parental Factors Associated with HPV Vaccine Receipt 
PLoS Medicine  2010;7(5):e1000270.
Analysis of a telephone survey by Gina Ogilvie and colleagues identifies the parental factors associated with HPV vaccine uptake in a school-based program in Canada.
Information on factors that influence parental decisions for actual human papillomavirus (HPV) vaccine receipt in publicly funded, school-based HPV vaccine programs for girls is limited. We report on the level of uptake of the first dose of the HPV vaccine, and determine parental factors associated with receipt of the HPV vaccine, in a publicly funded school-based HPV vaccine program in British Columbia, Canada.
Methods and Findings
All parents of girls enrolled in grade 6 during the academic year of September 2008–June 2009 in the province of British Columbia were eligible to participate. Eligible households identified through the provincial public health information system were randomly selected and those who consented completed a validated survey exploring factors associated with HPV vaccine uptake. Bivariate and multivariate analyses were conducted to calculate adjusted odds ratios to identify the factors that were associated with parents' decision to vaccinate their daughter(s) against HPV. 2,025 parents agreed to complete the survey, and 65.1% (95% confidence interval [CI] 63.1–67.1) of parents in the survey reported that their daughters received the first dose of the HPV vaccine. In the same school-based vaccine program, 88.4% (95% CI 87.1–89.7) consented to the hepatitis B vaccine, and 86.5% (95% CI 85.1–87.9) consented to the meningococcal C vaccine. The main reasons for having a daughter receive the HPV vaccine were the effectiveness of the vaccine (47.9%), advice from a physician (8.7%), and concerns about daughter's health (8.4%). The main reasons for not having a daughter receive the HPV vaccine were concerns about HPV vaccine safety (29.2%), preference to wait until the daughter is older (15.6%), and not enough information to make an informed decision (12.6%). In multivariate analysis, overall attitudes to vaccines, the impact of the HPV vaccine on sexual practices, and childhood vaccine history were predictive of parents having a daughter receive the HPV vaccine in a publicly funded school-based HPV vaccine program. By contrast, having a family with two parents, having three or more children, and having more education was associated with a decreased likelihood of having a daughter receive the HPV vaccine.
This study is, to our knowledge, one of the first population-based assessments of factors associated with HPV vaccine uptake in a publicly funded school-based program worldwide. Policy makers need to consider that even with the removal of financial and health care barriers, parents, who are key decision makers in the uptake of this vaccine, are still hesitant to have their daughters receive the HPV vaccine, and strategies to ensure optimal HPV vaccine uptake need to be employed.
Please see later in the article for the Editors' Summary
Editors' Summary
About 10% of cancers in women occur in the cervix, the structure that connects the womb to the vagina. Every year, globally, more than a quarter of a million women die because of cervical cancer, which only occurs after the cervix has been infected with a human papillomavirus (HPV) through sexual intercourse. There are many types of HPV, a virus that infects the skin and the mucosa (the moist membranes that line various parts of the body, including the cervix). Although most people become infected with HPV at some time in their life, most never know they are infected. However, some HPV types cause harmless warts on the skin or around the genital area and several—in particular, HPV 16 and HPV 18, so-called high-risk HPVs—can cause cervical cancer. HPV infections are usually cleared by the immune system, but about 10% of women infected with a high-risk HPV develop a long-term infection that puts them at risk of developing cervical cancer.
Why Was This Study Done?
Screening programs have greatly reduced cervical cancer deaths in developed countries in recent decades by detecting the cancer early when it can be treated; but it would be better to prevent cervical cancer ever developing. Because HPV is necessary for the development of cervical cancer, vaccination of girls against HPV infection before the onset of sexual activity might be one way to do this. Scientists recently developed a vaccine that prevents infection with HPV 16 and HPV 18 (and with two HPVs that cause genital warts) and that should, therefore, reduce the incidence of cervical cancer. Publicly funded HPV vaccination programs are now planned or underway in several countries; but before girls can receive the HPV vaccine, parental consent is usually needed, so it is important to know what influences parental decisions about HPV vaccination. In this study, the researchers undertake a telephone survey to determine the uptake of the HPV vaccine by 11-year-old girls (grade 6) in British Columbia, Canada, and to determine the parental factors associated with vaccine uptake; British Columbia started a voluntary school-based HPV vaccine program in September 2008.
What Did the Researchers Do and Find?
In early 2009, the researchers contacted randomly selected parents of girls enrolled in grade 6 during the 2008–2009 academic year and asked them to complete a telephone survey that explored factors associated with HPV vaccine uptake. 65.1% of the 2,025 parents who completed the survey had consented to their daughter receiving the first dose of HPV vaccine. By contrast, more than 85% of the parents had consented to hepatitis B and meningitis C vaccination of their daughters. Nearly half of the parents surveyed said their main reason for consenting to HPV vaccination was the effectiveness of the vaccine. Conversely, nearly a third of the parents said concern about the vaccine's safety was their main reason for not consenting to vaccination and one in eight said they had been given insufficient information to make an informed decision. In a statistical analysis of the survey data, the researchers found that a positive parental attitude towards vaccination, a parental belief that HPV vaccination had limited impact on sexual practices, and completed childhood vaccination increased the likelihood of a daughter receiving the HPV vaccine. Having a family with two parents or three or more children and having well-educated parents decreased the likelihood of a daughter receiving the vaccine.
What Do These Findings Mean?
These findings provide one of the first population-based assessments of the factors that affect HPV vaccine uptake in a setting where there are no financial or health care barriers to vaccination. By identifying the factors associated with parental reluctance to agree to HPV vaccination for their daughters, these findings should help public-health officials design strategies to ensure optimal HPV vaccine uptake, although further studies are needed to discover why, for example, parents with more education are less likely to agree to vaccination than parents with less education. Importantly, the findings of this study, which are likely to be generalizable to other high-income countries, indicate that there is a continued need to ensure that the public receives credible, clear information about both the benefits and long-term safety of HPV vaccination.
Additional Information
Please access these Web sites via the online version of this summary at
The US National Cancer Institute provides information about cervical cancer for patients and for health professionals, including information on HPV vaccines (in English and Spanish)
The US Centers for Disease Control and Prevention also has information about cervical cancer and about HPV
The UK National Health Service Choices website has pages on cervical cancer and on HPV vaccination
More information about cervical cancer and HPV vaccination is available from the Macmillan cancer charity
ImmunizeBC provides general information about vaccination and information about HPV vaccination in British Columbia
MedlinePlus provides links to additional resources about cervical cancer (in English and Spanish)
PMCID: PMC2864299  PMID: 20454567
9.  Parents Served by Assertive Community Treatment: Parenting Needs, Services, and Attitudes 
Assertive Community Treatment (ACT) is an evidence-based practice for individuals with severe mental illness. Although as many as half of all people with severe mental illness are parents, little is known about their experiences as parents and as recipients of mental health interventions, like ACT. The purpose of the current study was to examine the experiences of parent consumers served by ACT.
Seventeen parents being served by ACT teams were interviewed about parenting, parenting needs, severe mental illness, satisfaction with ACT services, and suggestions for improved parent-focused treatment services.
All parents identified at least one positive aspect of parenting and most (77%) also identified negative aspects of parenting. Loss of custody emerged as a significant parenting problem, with most parents (88%) experiencing custody loss at least once. Parents expressed interest in numerous parent-focused services, including family therapy, parenting skills, communication skills training, resources for children, and peer support groups. Most participants with adult children reported having no unmet parent-related needs (88%) and high satisfaction (4.63 of 5) with ACT services, whereas parents with young children reported having several unmet parenting needs (78%) and relatively lower satisfaction (3.78 out of 5) with ACT services.
Conclusions and Implications for Practice
The ACT treatment model may not be adequately serving parents of young, dependent children. Findings suggest the need for more attention and focus on parent consumers, including identification of parental status and improved parent-related treatment services and support.
PMCID: PMC3980453  PMID: 23477646
Assertive Community Treatment Services; Severe Mental Illness; Parenting; Needs Assessment
10.  Competency, confidence and conflicting evidence: key issues affecting health visitors' use of research evidence in practice 
BMC Nursing  2009;8:4.
Health visitors play a pivotal position in providing parents with up-to-date evidence-based care on child health. The recent controversy over the safety of the MMR vaccine has drawn attention to the difficulties they face when new research which raises doubts about current guidelines and practices is published. In the aftermath of the MMR controversy, this paper investigates the sources health visitors use to find out about new research evidence on immunisation and examines barriers and facilitators to using evidence in practice. It also assesses health visitors' confidence in using research evidence.
Health visitors were recruited from the 2007 UK Community Practitioners' and Health Visitors' Association conference. All delegates were eligible to complete the questionnaire if in their current professional role they advise parents about childhood immunisation or administer vaccines to children. Of 228 who were eligible, 185 completed the survey (81.1%).
These health visitors used a wide range of resources to find out about new research evidence on childhood immunisation. Popular sources included information leaflets and publications, training days, nursing journals and networking with colleagues. A lack of time was cited as the main barrier to searching for new evidence. The most common reason given for not using research in practice was a perception of conflicting research evidence. Understanding the evidence was a key facilitator. Health visitors expressed less confidence about searching and explaining research on childhood immunisation than evidence on weaning and a baby's sleep position.
Even motivated health visitors feel they lack the time and, in some cases, the skills to locate and appraise research evidence. This research suggests that of the provision of already-appraised research would help to keep busy health professionals informed, up-to-date and confident in responding to public concerns, particularly when there is apparently conflicting evidence. Health visitors' relative lack of confidence about research on immunisation suggests there is still a job to be done in rebuilding confidence in evidence on childhood immunisation. Further research on what makes evidence more comprehensible, convincing and useable would contribute to understanding how to bridge the gulf between evidence and practice.
PMCID: PMC2679743  PMID: 19379494
11.  “Everyone just keeps their eyes closed and their fingers crossed”: Sexual health communication among black parents and children in Nova Scotia, Canada 
Black Canadian youth remain disproportionally affected by an array of social and health issues, including sexually transmitted infections. While research exists in support of the involvement of parents as a key means to prevent or modify harmful behaviours among youth, less is known about how parent–child communication can serve as a prevention intervention strategy within Black families in Canada. This study explores sexual health communication between Black parents and youth in Nova Scotia and identifies facilitators, obstacles and issues that families face in dialoguing about sexual health.
Focus groups and in-depth interview sessions were held with a diverse sample of parents of Black youth, health and education professionals, and Black youth in Nova Scotia, as part of a larger study aimed at exploring parent–child communication on sexual health and HIV. The research team worked in partnership with and received feedback from key informants and a community advisory committee throughout the various stages of this study. All sessions were audio-taped with permission and thematic analysis was carried out on the verbatim transcripts.
Six key themes emerged from the data analysis in relation to parent–child communication within Black families in Nova Scotia: 1. the gendered nature of [sexual] health communication; 2. fear and uncertainty as obstacles; 3. open and honest dialogue from an early age as a facilitator; 4. media as both a catalyst and a barrier; 5. peers as a catalyst; and 6. time constraints as an obstacle.
The findings of this study reveal that parent–child communication regarding sexual health promotion within Black families in Nova Scotia remains varied and is heavily affected by a myriad of intersecting determinants of health faced by Black youth and their parents. Health promotion interventions aimed at fostering and supporting parent–child communication on sexual health must simultaneously target both parents and youth and further, such efforts must engage a high level of cultural competency in order to better meet the needs of this population.
PMCID: PMC3765904  PMID: 23876177
Sexual health; Black youth; Parents; Qualitative research; Nova Scotia; Communication
12.  Barriers to successful recruitment of parents of overweight children for an obesity prevention intervention: a qualitative study among youth health care professionals 
BMC Family Practice  2012;13:37.
The recruitment of participants for childhood overweight and obesity prevention interventions can be challenging. The goal of this study was to identify barriers that Dutch youth health care (YHC) professionals perceive when referring parents of overweight children to an obesity prevention intervention.
Sixteen YHC professionals (nurses, physicians and management staff) from eleven child health clinics participated in semi-structured interviews. An intervention implementation model was used as the framework for conducting, analyzing and interpreting the interviews.
All YHC professionals were concerned about childhood obesity and perceived prevention of overweight and obesity as an important task of the YHC organization. In terms of frequency and perceived impact, the most important impeding factors for referring parents of overweight children to an intervention were denial of the overweight problem by parents and their resistance towards discussing weight issues. A few YHC professionals indicated that their communication skills in discussing weight issues could be improved, and some professionals mentioned that they had low self-efficacy in raising this topic.
We consider it important that YHC professionals receive more training to increase their self-efficacy and skills in motivating parents of overweight children to participate in obesity prevention interventions. Furthermore, parental awareness towards their child’s overweight should be addressed in future studies.
PMCID: PMC3403855  PMID: 22591134
13.  Improving Health Outcomes of Children through Effective Parenting: Model and Methods  
This article reports on the design, development, testing and presentation of preliminary evidence of a translational, culturally relevant parenting education model, titled Smart and Secured Children (SSC). SSC, a quality parenting curriculum, prepares disparate African American parents as leaders for transforming their parenting behaviors and leading their peers and community in changing existing parenting culture. The article recommends expanded utility of identified promising processes, approaches and practices to engage African American parents to lead in addressing health inequity conditions in their families and communities. It adds to the growing scientific literature on the association between parent–child relationship quality and a wide variety of children physical, emotional and social outcomes. SSC applied principles of developmental theories; community based participatory research (CBPR), and iterative Delphi method between the community stakeholders, parents and researchers. The delivery approach of SSC was revamped from professional-led to parent-led content presentation and delivery methods using a conversational learning approach, referred to as ‘conversepedia’. Parents’ leadership development training and delivery of this curriculum in social supportive groups improved their mental wellbeing, parenting capacity and leadership skills. Parents do matter and can choose positive influence in their lives and are capable of reversing negative peer influence.
PMCID: PMC3924445  PMID: 24366048
parenting; smart and secure children; child development; emotional wellbeing; mental health; community-based participatory research; conversepedia
14.  The interactions of ethical notions and moral values of immediate stakeholders of immunisation services in two Indian states: a qualitative study 
BMJ Open  2013;3(3):e001905.
This study examines the existing norms regarding immunisation within the communities and the ethical notions that govern the actions of different health professionals and their collective synergistic or conflicting effects on the governance of the programme.
We used descriptive and analytical qualitative methods as it suited the research question.
The data were collected from areas under 16 primary health centres in Kerala and Tamil Nadu identified through a three-step sampling process.
This involved in-depth interviews with stakeholders including providers, beneficiaries and other stakeholders, focus group discussions with mothers of under-five children and participant and non-participant observations of vaccination-related activities.
Unlike most other ethical analyses that look at the ethics of vaccination policies, the interactions of normative principles and notions are analysed in this article. Moral obligation of parents towards their children, beneficence of healthcare providers and the utilitarian aspirations of the state are the key normative principles involved. Our analysis points to the interplay of both synergy and conflict in ethical notions and moral values in the context of immunisation services. Paternalistic interventions like special immunisation campaigns against polio and Japanese encephalitis are a case in point: they generate conflict at the normative level and create mistrust.
Analysis of vaccination policies and programmes needs to go beyond factors that assess monetary benefits or herd immunity. Understanding the interactions of normative notions that shape the social organisation of the providers and the users of vaccination is important in creating a sustainable environment for the programme.
PMCID: PMC3612786  PMID: 23457322
Ethics (see Medical Ethics); Primary Care; Social Medicine
15.  Beliefs and Knowledge about Vaccination against AH1N1pdm09 Infection and Uptake Factors among Chinese Parents 
Vaccination against AH1N1pdm09 infection (human swine infection, HSI) is an effective measure of preventing pandemic infection, especially for high-risk groups like children between the ages of 6 months and 6 years. This study used a cross-sectional correlation design and aimed to identify predicting factors of parental acceptance of the HSI vaccine (HSIV) and uptake of the vaccination by their preschool-aged children in Hong Kong. A total of 250 parents were recruited from four randomly selected kindergartens. A self-administered questionnaire based on the health belief framework was used for data collection. The results showed that a number of factors significantly affected the tendency toward new vaccination uptake; these factors included parental age, HSI vaccination history of the children in their family, preferable price of the vaccine, perceived severity, perceived benefits, perceived barriers, and motivating factors for taking new vaccines. Using these factors, a logistic regression model with a high Nagelkerke R2 of 0.63 was generated to explain vaccination acceptance. A strong correlation between parental acceptance of new vaccinations and the motivating factors of vaccination uptake was found, which indicates the importance of involving parents in policy implementation for any new vaccination schemes. Overall, in order to fight against pandemics and enhance vaccination acceptance, it is essential for the government to understand the above factors determining parental acceptance of new vaccinations for their preschool-aged children.
PMCID: PMC3945580  PMID: 24534766
Chinese parents; community care; health belief model; influenza vaccination; parents; preschool children
16.  Professional Caregiver's View on Mental Health in Parents of Children with Developmental Disabilities: A Nationwide Study of Institutions and Consultation Centers in Japan 
ISRN Pediatrics  2012;2012:121898.
Parents of children with intellectual disabilities and/or physical disabilities are supposed to have an increased risk for parenting stress and psychological distress. We as professional caregivers sometimes experience difficulties in keeping good relations or communicating with the parents. Professional workers in 460 institutions and consultation centers throughout Japan answered a questionnaire on their clinical experiences. About 90% of the facilities experienced “distressed parents,” and the parents' condition such as mental health seemed to influence this. Signs of a depressive state were the most common psychiatric disturbances detected, and it was notable in the pervasive developmental disorder group. More welfare support, presence of support groups, support from other family members, and medical treatment of the parents' problems were considered to be helpful and thus requested to be improved. Training more professionals who can properly deal with the parents' mental health needs is an urgent matter that must be tackled.
PMCID: PMC3265212  PMID: 22389791
17.  Parents' opinions of mandatory Human Papillomavirus (HPV) vaccination: does ethnicity matter? 
To explore parents' opinions of school-entry requirements for Human Papillomavirus (HPV) vaccination.
We interviewed parents of vaccine-eligible girls attending medical appointments in an urban academic medical center and an affiliated community health center. We used qualitative methods to explore parents' opinions about mandating routine childhood vaccines and HPV vaccine, as well as their feelings about vaccinating their own daughters against HPV.
19 Caucasian, 18 African-American, 12 Afro-Caribbean, 3 African, and 21 Latino parents participated. Nearly all parents had allowed their children to receive routine vaccinations and expressed support for mandating these vaccines. Most parents also vaccinated their daughters against HPV: 100% of Caucasian parents, 90% of African-American parents, 73% of Afro-Caribbean/African parents, and 90% of Latino parents. Only 11% of Caucasian parents supported HPV vaccine mandates, however, compared with 78% of African-American, 60% of Afro-Caribbean/African and 90% of Latino parents. Immigrants supported mandates more frequently than U.S.-born parents. Most Caucasian parents opposed mandatory HPV vaccination because they believed the HPV vaccine should be an individual decision as the virus could only be spread by sexual contact. African-American, Afro-Caribbean, African and Latino parents generally viewed mandates as the most effective way to protect their daughters from cervical cancer. Latino parents gave special importance to protecting their daughters from sexually transmitted infections.
Parents from different racial and ethnic backgrounds expressed unique perspectives about mandatory HPV vaccination, and Caucasians were less likely than parents of other races/ethnicities to support vaccine mandates.
PMCID: PMC3032271  PMID: 21051001
18.  Measles immunisation: feasibility of a 90% target uptake. 
Archives of Disease in Childhood  1987;62(12):1209-1214.
A three part investigation of the factors that might influence uptake of immunisation was carried out in Maidstone Health Authority; this included studies of the computer system and attitudes of parents and professionals. Several problems with immunisation scheduling, information transfer between general practitioners and clinics and the computer centre, and validity of computer information were identified. The attitudes of parents, relatives, and friends were generally favourable, although parents reported a lack of knowledge about the disease and vaccine and lack of advice from professionals. Perceived contraindications to immunisation, particularly a history of measles, were important reasons for non-uptake. Professionals' perceptions of contraindications, however, were at variance with Department of Health and Social Security guidelines and none of the recorded contraindications was valid. Calculations of potential uptake suggest that a 90% target uptake is feasible and recommendations are made for changes in services.
PMCID: PMC1778613  PMID: 3435154
19.  Designing a web-application to support home-based care of childhood CKD stages 3-5: Qualitative study of family and professional preferences 
BMC Nephrology  2014;15:34.
There is a lack of online, evidence-based information and resources to support home-based care of childhood CKD stages 3-5.
Qualitative interviews were undertaken with parents, patients and professionals to explore their views on content of the proposed online parent information and support (OPIS) web-application. Data were analysed using Framework Analysis, guided by the concept of Self-efficacy.
32 parents, 26 patients and 12 professionals were interviewed. All groups wanted an application that explains, demonstrates, and enables parental clinical care-giving, with condition-specific, continously available, reliable, accessible material and a closed communication system to enable contact between families living with CKD. Professionals advocated a regularly updated application to empower parents to make informed health-care decisions. To address these requirements, key web-application components were defined as: (i) Clinical care-giving support (information on treatment regimens, video-learning tools, condition-specific cartoons/puzzles, and a question and answer area) and (ii) Psychosocial support for care-giving (social-networking, case studies, managing stress, and enhancing families’ health-care experiences).
Developing a web-application that meets parents’ information and support needs will maximise its utility, thereby augmenting parents’ self-efficacy for CKD caregiving, and optimising outcomes. Self-efficacy theory provides a schema for how parents’ self-efficacy beliefs about management of their child’s CKD could potentially be promoted by OPIS.
PMCID: PMC3933188  PMID: 24548640
Interactive health communication applications (IHCA); Self-efficacy; Online parent information and support (OPIS) application; Chronic kidney disease (CKD); Children; Clinical support; Parental care-giving; Long-term
20.  Opinions of Quebec parents and vaccinators on the usefulness of chickenpox vaccine 
A chickenpox vaccine was recently licensed in Canada. Because this vaccine has caused some controversy within the health care profession, studies among Quebec parents and vaccine providers were carried out, surveying their opinions concerning chickenpox vaccination.
Three studies among parents of preadolescents, parents of two-year-old children completely or incompletely vaccinated and vaccinators were completed. The studies asked for opinions concerning the usefulness of vaccinating children against chickenpox.
The majority of parents of preadolescents (56%), and parents of two-year-old children completely (64%) and incompletely vaccinated (60%) favoured chickenpox vaccination. Among vaccinators, 53% of paediatricians, 37% of general practitioners and 33% of nurses considered universal vaccination of young children to be useful. A greater proportion of health care professionals were in favour of a policy of vaccinating groups at risk, such as susceptible adolescents (86%, 75% and 58%, respectively). There was a positive association between the perceived severity of chickenpox and the potential usefulness of the vaccine.
Quebec parents are more favourably disposed to chickenpox vaccine than vaccine providers. In contrast, strategies targeting susceptible groups would be generally well received by health care professionals. A considerable amount of work will be needed to convince vaccinators of the benefits of a universal childhood vaccination against chickenpox.
PMCID: PMC2094808  PMID: 18159333
Chickenpox; Immunization programs; Parental opinions; Vaccinator opinions; Varicella vaccine
21.  Failure to vaccinate against whooping cough. 
Archives of Disease in Childhood  1986;61(4):382-387.
We describe a prospective study in which we investigated why children fail to get vaccinated against whooping cough, including an assessment of the attitudes of parents and professionals and the impact of different views of the contraindications. There was considerable disagreement among the professionals on the interpretation of the contraindications to immunisation, and the commonest reason for omitting pertussis vaccine was advice from the doctor based on dubious contraindications. When faced with parents anxious about the risks of immunisation health professionals are unable to find reassurance in the list of contraindications to immunisation.
PMCID: PMC1777774  PMID: 3707190
22.  Assessment of parental acceptance of a potential cytomegalovirus vaccine for adolescent females 
Vaccine  2010;28(35):5686-5690.
The development of a vaccine against cytomegalovirus (CMV) has been designated as a high priority and adolescent females are a likely target population for CMV vaccination. A self-administered, internet-based survey was developed using constructs from the Health Belief Model to identify factors that may be associated with parental acceptance of a CMV vaccine for their adolescent daughters. Data from 516 parents were analyzed, the majority of whom were female, white, and college educated. Parental acceptance of a CMV vaccine was generally high. Perceived benefits of vaccine were independently associated with vaccine acceptance while history of previous vaccine refusal, concerns about safety and cost of the vaccine were negatively associated. These findings provide initial data on factors that are likely to influence parental acceptance of a CMV vaccine for adolescent girls.
PMCID: PMC3773717  PMID: 20600495
Acceptance; Cytomegalovirus; Adolescents; Parents
23.  MMR: marginalised, misrepresented and rejected? Autism: a focus group study 
Archives of Disease in Childhood  2007;92(4):322-327.
To explore how the measles, mumps, and rubella (MMR) vaccine controversy impacted on the lives of parents caring for children with autism.
Qualitative focus group study.
United Kingdom.
A purposively selected sample of 38 parents took part in 10 focus group discussions between March 2003 and May 2005.
Many parents felt that the MMR vaccine could be too potent for children who are susceptible to developing autism. Of the parents whose children received the MMR vaccine, many felt guilty that they may have caused or contributed to their child's autism. Some parents felt frustrated by health professionals' lack of understanding of the negative impact the MMR controversy has had on them. Some parents were anxious about subsequent MMR decision‐making for their children.
The controversy has had a negative impact on some parents of children with autism. This has implications for health professionals, who need to be particularly aware of the issues these parents face in future MMR decision‐making for their affected child and younger siblings. It is anticipated that these findings will raise awareness among health professionals of the difficulties faced by such parents. More generally, there is a need to promote a greater awareness of the important role health visitors can play in parental decision‐making and for research examining whether health professionals feel they receive sufficient training in communication skills. It is also essential that the latest scientific research findings are disseminated quickly to these parents and to those health professionals advising parents on matters of vaccine safety.
PMCID: PMC2083659  PMID: 17376937
24.  Randomised controlled trial of the use of a modified postal reminder card on the uptake of measles vaccination 
Archives of Disease in Childhood  1998;79(2):136-140.
OBJECTIVE—To determine whether rewording postal reminder cards according to the "health belief model", a theory about preventive health behaviour, would help to improve measles vaccination rates.
DESIGN—A randomised controlled trial, with blind assessment of outcome status. Parents of children due for their first measles vaccination were randomised to one of two groups, one receiving the health belief model reminder card, the other receiving the usual, neutrally worded card. The proportion of children subsequently vaccinated in each group over a five week period was ascertained from clinical (provider based) records.
SETTING—A local government operated public vaccination clinic.
PARTICIPANTS—Parents of 259 children due for measles vaccination.
MAIN RESULTS—The proportion of children vaccinated in the health belief model card group was 79% compared with 67% of those sent the usual card (95% CI, 2% to 23%), a modest but important improvement.
CONCLUSION—This study illustrates how the effectiveness of a minimal and widely practised intervention to promote vaccination compliance can be improved with negligible additional effort.

PMCID: PMC1717666  PMID: 9797594
25.  Communication skills training for parents: experimental and social validation. 
Coordination of professional services of behalf of children often hinges on the involvement of informed parents. The purposes of this study were to identify and experimentally and socially validate skills required of parents for effective communication with professionals. Target skills were identified on the basis of judges' social validation ratings of (a) sample interactions between parents and professionals and (b) the behaviors comprising a resultant task analysis. Eight parents were then trained in these skills via an instructional package. Results of a multiple baseline design across subjects and grouped skill domains showed that each parent acquired the targeted skills during simulated conferences and that correct responding usually generalized to actual conferences. Independent judges validated training outcomes, and participating parents indicated satisfaction with the curriculum.
PMCID: PMC1286090  PMID: 3372402

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