3- 5 pages research paper writing from research article

22 PEDIATRIC NURSING/January-February 2017/Vol. 43/No. 1

T he first vaccine was intro- duced over 200 years ago and has forever changed the world we live in today (Stern

& Markel, 2005). With the help of vaccines, people are able to build anti- bodies that enable and create a defense against illnesses, such as rabies, tetanus, typhoid fever, influen- za, measles, pneumococcal, meningo- coccal disease, haemophilus influen- zae, and other vaccine-preventable ill- nesses. Vaccination efforts and health policy have been an integral compo- nent in the prevention and the fight of unwanted infectious diseases in our local communities. Unfortunately, with the success of vaccines, the fear of contracting a vaccine-preventable disease has diminished (Offit, 2011).

During the past 10 years, the rate of parents refusing vaccines has increased, causing the risk of infec- tious disease to the young and old to also increase (Dempsey et al., 2011). Currently, one in 10 parents report the use of an alternative vaccine schedule (AVS) (Cooper, Larson, & Katz, 2008). An AVS is any vaccine schedule that deviates from the recommended Centers for Disease Control and Prevention (CDC) schedule. In a typi- cal month, 89% of healthcare providers report parents request to fol- low an AVS, administer one vaccine per visit, or refuse vaccines altogether. As a result, 95% of healthcare providers state that the amount of

Arizona, allow personal beliefs exemptions (Institute for Vaccine Safety, 2012). School exemption rates in the state of Arizona have doubled in the last 10 years and increased 0.8% in one year from 2012-2013 since the implementation of personal belief exemptions (Arizona Depart - ment of Health Services, 2014; CDC, 2012). In the 2013-2014 Arizona school year, a total of 4,035 kinder- gartners (4.7%) filed for vaccine exemption (Arizona Department of Health Services, 2014). In fact, in 2013, only 69% of children in Arizona were protected from the seven vaccine series compared to 72% nationally (Arizona Department of Health Services, 2013b). Birnbaum et al. (2013) from the University of Arizona found that schools with sig- nificantly higher rates of personal belief exemptions included schools with the highest proportion of higher income white students and lowest proportion of free and reduced lunches.

These vaccine statistics are con- cerning and definitely affect other communities across the U.S. As of April 10, 2015, there was one large measles outbreak at a Disney theme park, contributing to smaller out-

time it takes to discuss parents’ con- cerns about vaccines is a major barrier to practice (Kempe et al., 2011).

While the current national vac- cine rate remains high enough to develop herd immunity, there are growing pockets in the United States (U.S.) with low vaccination rates, mak- ing herd immunity nearly impossible to obtain (CDC, 2014). Many parents of today are more concerned with pos- sible side effects from vaccines and are refusing to vaccinate their children from the deadly diseases of our past and the present (Offit, 2011). The increased rate of refusal and use of AVS are threats to our communities. Once the vaccine rate falls below 95%, a community loses its herd immunity, and outbreak may occur (Mennito & Darden, 2010). When compared to parents who follow the CDC schedule, only 28% of parents who follow an AVS strongly agreed that their child was more at risk for contracting dis- ease and contributing to the spread of vaccine-preventable diseases (Dempsey et al., 2011).

In the U.S., current vaccine laws require vaccinations upon kinder- garten entry (Birnbaum, Jacobs, Ralston-King, & Ernst, 2013). Nine - teen U.S. states, including the state of

An increase in vaccine hesitancy is contributing to an increase of vaccine refusal and the use of an alternative vaccine schedule (AVS) in the United States. Increasing vaccine knowledge and correcting vaccine misinformation has the potential of shifting parental attitudes, decreasing vaccine hesitancy, and increasing parental intent to vaccinate. The aim was to examine the impact of a voice-over PowerPointTM presentation on vaccine education and decision-mak- ing by vaccine-hesitant parents in a pediatric primary care clinic. A quasi-experi- mental study using the Parent Attitude about Childhood Vaccine (PACV) Survey was conducted in a suburban pediatric clinic to explore the impact of vaccine education on decision-making by vaccine-hesitant parents. PACV Survey scores were collected over three months. Surveyed parents reported they trust their healthcare provider. Unfortunately, although parents trust the information their medical providers give them on vaccine safety, they continue to be concerned about vaccine side effects. Mothers tended to provide more vaccine-hesitant scores than fathers related to safety and efficacy concerns. The utilization of the PACV Survey and voice-over PowerPoint presentation on vaccine education is an intervention that may be used in pediatric clinics to assist in vaccine education and identify vaccine-hesitant parents. The study contributes to the addition of evi- dence-based vaccine education.

Amy Zangger Eby, DNP, CPNP, is a Pediatric Nurse Practitioner, All Star Pedia - trics, Gilbert, AZ. The author may be contact- ed directly at [email protected]

Acknowledgement: The author would like to thank the Beta Upsilon and Lambda Phi Chapter of Sigma Theta Tau for awarding her the Nancy Melvin Research Grant and the Rising Star Sponsorship Award. In addition, the author is very grateful for the time, guid- ance, and support of the many professors that have supported her goal to become a published author. The author would like to acknowledge Lyla Lindholm, DNP, RN, ACNS-BC, and Gail Hock, MS, RN, PHCNS- c, for their guidance along this journey.

Impacting Parental Vaccine Decision-Making

Amy Zangger Eby

PEDIATRIC NURSING/January-February 2017/Vol. 43/No. 1 23

breaks in 18 states and causing a total of 159 cases of measles during early 2015 (CDC, 2015). This latest out- break includes 16% of the total cases documented in 2014 (CDC, 2015). The cost to treat a child with measles is 23 times the amount spent on the measles, mumps, rubella (MMR) vac- cine (Armstrong, 2007). Vaccinating a child against diphtheria, tetanus, acellular pertussis (DTaP), haemo - philus influenza (HIB), MMR, and Hepatitis B (Hep B) provides a cost savings of 5:1 in direct healthcare spending and 17:1 in societal costs (Lieu, McGuire, & Hinman, 2005). As a result, vaccinating 90% of children from 1994-2013 is estimated to have saved society $1.38 trillion dollars in total societal cost over the lifetime of children born during this time span (CDC, 2014). The current CDC im - munization schedule could prevent approximately 322 million illnesses, 21 million hospitalizations, and 732,000 deaths, and save the U.S. 69 billion dollars spent by the health care industry treating vaccine preventable diseases (CDC, 2014; National Committee for Quality Assurance, 2013).

Pediatricians and other health- care providers are concerned with the increased number of families choos- ing to not vaccinate or follow an AVS (Committee on Practice and Ambu - latory Medicine and Council on Com munity Pediatrics, 2010). The U.S. government has noticed the changes and has set vaccine goals in the Healthy People 2020 report (Koh, 2010). In addition, the state of Arizona implemented an action plan in 2013 to decrease vaccine exemp- tions, affirming the state’s commit- ment to help educate the public on vaccine preventable diseases (Arizona Department of Health Services, 2013a).

Purpose and Aims The purpose of this study was to

examine the impact of vaccine educa- tion via voice-over PowerPointTM on decision-making by vaccine-hesitant parents. The PowerPoint presentation aimed to rectify misinformation cur- rently circulating about vaccines. The study goal is contributing to practice knowledge needed to validate brief office vaccine education in decreasing the number of infants following an AVS, thus increasing the number of infants fully vaccinated according to CDC recommendations.

vaccine education prenatally two times more often in vaccine-hesitant parents and those who refuse to vac- cinate than parents who follow the CDC-recommended vaccine schedule (p < 0.0007). In addition, parents con- stantly re-evaluate vaccine decision- making eight times more often in the vaccine-hesitant group than the group that follows the CDC schedule (p < 0.0001). The study reiterates the importance of continuing to educate parents who initially follow an AVS or refuse vaccines altogether. The authors concluded that parents need to be educated at multiple time points as they contemplate their vaccine decision-making and choices.

A pretest/posttest study consist- ing of a 60-minute PowerPoint pres- entation on the understanding of human papilloma virus (HPV), which also included time for group discus- sion, evaluated parents’ HPV knowl- edge and intent to vaccinate daugh- ters (Spleen, Klauhsman, Clark, Dignan, & Longerich, 2012). The study results showed a significant increase in HPV and vaccine knowl- edge (p < 0.0001). According to the posttest data, vaccine intent by par- ents statistically increased (p = 0.002).

A similar study analyzed the effect of an educational PowerPoint presentation on HPV knowledge (Reiter, Stubbs, Whitesell, & Brewer, 2011). The total sample size was 950 subjects, which included parents, healthcare staff, and school staff. Study subjects had low levels of HPV and HPV vaccine knowledge. The study was a pretest/posttest study and demonstrated a statistically signifi- cant increase in HPV knowledge in all subject groups (p < 0.001).

In a randomized clinical trial, a pre-survey/post-survey design using the Parental Attitude about Child - hood Vaccine (PACV) Survey evaluat- ed the impact of an educational pro- gram on vaccination (Williams et al., 2013). The intervention group was exposed to an education presentation on vaccination safety. The control group received a well-check ex - amination as normal. The researchers determined there was a decrease in vaccine hesitancy in the intervention group that was statistically signifi- cant, with a medium difference of 6.7 points in the second survey (p = 0.49). In both the control and intervention group, 89.6% of parents stated their healthcare provider was a source of trusted vaccine information.

Literature Review A systematic review of qualitative

studies on beliefs, attitudes, and barri- ers toward childhood vaccination analyzed 15 studies (Mills, Jadad, Ross, & Wilson, 2005). A total of seven barriers were identified as themes and included the concern of adverse risk, pain with vaccine administration, distrust by those advocating vaccines, conspiracy theo- ries about pharmaceutical companies, vaccine administration during illness, lack of vaccine schedule awareness, and poor communication from healthcare providers. The authors concluded that healthcare providers need to address barriers through edu- cation. Emphasis of gaining trust, showing respect to parents’ vaccine concerns, and decision-making was crucial to changing vaccine belief.

A systematic review of interven- tions for reducing vaccine hesitancy and refusal analyzed 30 quantitative studies (Sadaf, Richards, Glanz, Salmon, & Omer, 2013). Seventeen studies tested the impact of written educational information, PowerPoint presentation, and web-based decision making. A total of eight studies report- ed statistical significance on parents’ attitudes toward vaccines after partici- pation in vaccine education. Five stud- ies reported a statistical significance on parents’ intent to vaccinate. The authors identified a gap in knowledge, encouraging additional studies to eval- uate the effect of delivering vaccine information through different media to better impact vaccination rates among those who refuse to vaccinate.

A mixed methods study by Glanz et al. (2013) on parental vaccine deci- sion-making and parent provider trust included seven focus groups of parents from Kaiser Permanente Colorado Health System. Three themes were identified. First, parents have signifi- cant trust in their healthcare providers, but they also have a lack of trust in vaccine safety and information on side effects given to parents from their healthcare pro viders. Second, parents identified that vaccine decision-mak- ing begins prenatally. Lastly, vaccine decision-making is an evolving process that occurs over the first several years of an infant’s life.

Information from focus groups was used to develop a survey that was mailed to parents (Glanz et al., 2013). Analysis of survey responses conclud- ed that parents begin the process of

24 PEDIATRIC NURSING/January-February 2017/Vol. 43/No. 1

In summary, research studies reveal a need for cost-effective inter- ventions that can easily be imple- mented in the primary care setting. By increasing vaccine knowledge, cor- recting vaccine misinformation, and changing parents’ attitude toward vaccines, an impact can be made on parents’ intent to vaccinate. Study outcomes on the measurement of vac cine rate, alternative vaccine schedule, attitude toward vaccina- tion, and the intent to vaccinate will likely impact future pediatric practice.

Theoretical Framework The theoretical framework of the

Health Belief Model consists of four constructs. The first is perceived sus- ceptibility, which includes the individ- ual’s perceived risk to a particular health issue (Janz & Becker, 1984). The second is perceived severity, or how serious the individual feels the health condition really is and how this partic- ular health condition affects possible social consequences. The third is per- ceived benefits, which explain how the proposed behavior will benefit the individual (Janz & Becker, 1984). The fourth concept is perceived barriers, which are the negative effects of the proposed behavioral change or the basic roadblocks inhibiting change. An education presentation on immuniza- tions can be targeted to act on all four levels of the model for the clinic’s spe- cific population.

Becker (1974) stated that threat appeal was also relevant to the Health Belief Model. Threat appeals are mes- sages that depict various health risks, which are often related in high-risk messages a recipient could experi- ence, as well as a vulnerability to dis- ease (Becker, 1974). The Health Belief Model affirms that if a person is aware of a health risk, then the person is more likely to try and prevent the health risk and lead a healthier lifestyle (Janz & Becker, 1984). As a result, parents’ perception of vaccine safety is one of the most significant indicators on whether parents intend to follow the current immunization recommendations (Smith, Kennedy, Wooten, Gust, & Pickering, 2006).

Methods

Ethical Issues The study was approved by prac-

tice owners at the research site, as well

includes 15 questions covering three separate domains that include behav- ior, safety and efficacy, and general attitudes. The questions are answered in a yes/no and Likert scale format. A score greater than 20 on the PACV Survey indicates vaccine hesitation.

Demographic information was collected on both the experimental and control groups, and included the parents’ marital status, number of children, insurance status, and eth- nicity. The demographic information provided additional data to ensure the similarity between both study groups. Demographic information was helpful in exploring potential fac- tors impacting intent to vaccinate, use of an alternative vaccine schedule, and refusal of all vaccines during well- check examinations.

Procedure After obtaining consent, the

PACV Survey was given to parents with newborns at the first clinic appointment. Parents who scored greater than 20 continued in the study. Participants enrolled at Site 1 were placed into the experimental group, and the subjects enrolled at Site 2 were placed into the control group. Prior to the infant’s examina- tion, participants in the experimental group watched a six-minute voice- over PowerPoint presentation created by the investigator to address parental concerns on vaccines. The control group received the standard vaccina- tion education given by their health- care provider. In both groups, the healthcare provider discussed the rec- ommended vaccines and vaccine side effects at the one and two months well-check examination, as well as answered parents’ questions regard- ing recommended vaccines.

The educational voice-over Power - Point presentation on vaccines includ- ed information on how vaccines work with the immune system, vaccine safe- ty, vaccine ingredients, side effects of vaccines, why vaccines are a healthy choice, and why vaccines should not be given on a different schedule. The PowerPoint was viewed privately by study participants. Vaccine informa- tion for the educational video was obtained from Voices for Vaccines, which is a nonprofit organization set up to promote vaccine awareness, the Children’s Hospital of Philadelphia, and the CDC (CDC, n.d.; Children’s Hospital of Philadelphia, 2013; Voices for Vaccines, n.d.).

as the Institutional Review Board at a university setting. The study investi- gator was also the primary care provider for some of the families enrolled in the study. To decrease bias, medical assistants recruited par- ticipants and obtained written informed consent. The study investi- gator was awarded the Nancy Melvin Research Grant from Sigma Theta Tau, Beta Upsilon Chapter, which helped cover supplies and assistance with data collection.

Design The research was a quasi-experi-

mental study that explored the impact of an evidence-based vaccine education program on decision-mak- ing by vaccine-hesitant parents. The proposed study was a non-random- ized control group pretest/posttest design. The conditions were the same for both the experimental and control groups, with the exception of expo- sure to the intervention.

Participants The setting was a suburban pedi-

atric private practice in the Phoenix Metropolitan area that includes two offices. The offices are located 10 miles apart and have similar patient demographics. Both study sites are composed of families in the upper socioeconomic group, and less than 10% of families are on Medicaid. Study participants were obtained via convenience sampling, which includ- ed parents who scored greater than 20 on the PACV survey and had a new- born with a first visit to the practice. Participants were assigned to either a control or an experimental group. A priori power analysis was conducted with G*Power v. 3.1.7 to estimate a sufficient sample size of 158.

Instrument Parent hesitancy toward vaccines

was assessed with the use of the PACV Survey. The survey was created by Douglas Opel and was shown to be a valid survey to identify vaccine-hesi- tant parents who often follow an AVS (Opel et al., 2011). Research was com- pleted with 230 subjects to determine the validity and reliability of the PACV Survey. Cronbach’s alpha coef- ficients for the three sub-domain scales were 0.74, 0.84, and 0.74. The PACV Survey is a self-administered survey taking less than five minutes for a parent to complete and is writ- ten at a sixth grade level. The survey

PEDIATRIC NURSING/January-February 2017/Vol. 43/No. 1 25

At the two-month well-check examination, the post-PACV Survey was planned to be administered to evaluate any change in survey score in both the experimental and control groups. A review of the electronic health record was completed at the end of the study to assess the number of parents with infants who were fol- lowing the routine CDC-recommend- ed schedule versus an AVS.

Data Analyses Data were collected from Decem -

ber 2014 through February 2015. The immunization status and family demographic information of infants enrolled in the study were analyzed. Pre-PACV Survey results were ana- lyzed using descriptive statistics. Demographic items and PACV scores were also compared using Kendall rank correlation. Pre- and post-PACV scores were projected to be compared using a paired t-test.

Behavioral/Safety and Efficacy Sub-Domain

The behavior sub-domain of the PACV Survey consisted of two items (see Tables 1-3). The items asked par- ents to report whether they had ever delayed or decided not to have their child receive a vaccine for reasons other than illness or allergy. Only one of the 23 participants (4.3%) reported having delayed vaccination or decid- ed against having an immunization.

The responses to items within the Safety and Efficacy sub-domain (see Tables 1-3) were associated with four survey entries. Item #9 asked parents to rate whether they agreed that it was better for children to get fewer vaccines at the same time. The responses were unimodal and essen- tially symmetrical, with about half the sample stating not sure (52%), five cases disagreeing with the state- ment, and one case reporting strong

Results Parents completed the pre-PACV

Survey at their infant’s first visit to the pediatric medical clinic, and no post- PACV surveys were completed. Post- PACV surveys were not obtained due to a lack of participants who met inclusion criteria. There was no com- parison group at the closure of the study because only one subject met study criteria for enrollment. Pre- PACV data were obtained from 23 cases, 22 of which adhered to the CDC-recommended immunization schedule at chart review (see Tables 1- 3). Data from pre-PACV surveys were analyzed, and adherence to the CDC- recommended immunization sched- ule was assessed via a chart review when infants were approximately two months old to determine any associa- tions between parental attitudes and children’s immunization status.

Table 1. Parent Attitude about Childhood Vaccine (PACV) Survey Items within Behavior Sub-Domain

Number Description

Response Formats, Scoring, and Obtained Frequencies

Y 2

N 0

DK Excluded

3 Have you ever delayed having your child get a shot (not including seasonal flu) for reasons other than illness or allergy?

1* 22 0

4 Have you ever decided not to have your child get a shot (not including seasonal flu shots) for reasons other than illness or allergy?

1* 22 0

Notes: Response format: Yes/No/Don’t know. *Non-adherent case.

Table 2. Parent Attitude about Childhood Vaccine (PACV) Survey Items within Safety and Efficacy Sub-Domain

Number Description

Response Formats, Scoring, and Obtained Frequencies

SA 2

A 2

NS 1

D 0

SD 0

9 It is better for children to get fewer vaccines at the same time. 1 4 12* 5 1 NAC 0

NTC 0

NS 1

SC 2

VC 2

10 How concerned are you that your child might have a serious side effect from a shot?

4 9 0 10* 0

11 How concerned are you that anyone of the childhood shots might not be safe?

6 9 2 6* 0

12 How concerned are you that a shot might not prevent the disease? 5 10 2 6* 0 Notes: Response formats for items: 9 = strongly agree/agree/not sure/disagree/strongly disagree; 10 to 12 = not at all concerned/not too concerned/not sure/somewhat concerned/very concerned. *Non-adherent case.

26 PEDIATRIC NURSING/January-February 2017/Vol. 43/No. 1

agreement and strong disagreement each. Items #10 through #12 asked parents to rate how concerned they were with regard to vaccine side effects, safety, and efficacy. Responses to the three items showed similar bimodal patterns. The majority of cases stated they were not at all con- cerned or not too concerned. When combined, 56% of parents were not concerned about vaccine side effects, 65% of parents were not concerned with vaccine safety, and 65% of par- ents were not concerned about vac- cine efficacy. A second mode of cases reported that 43% of parents were somewhat concerned about side effects, and 26% of parents were somewhat concerned about vaccine safety. Few participants reported being not sure, and there were no par- ents who reported being very con- cerned about these issues.

receiving a shot. Fifteen participants (65%) disagreed or strongly dis- agreed;, three parents were not sure (13.0%), and five participants (21.7%) agreed or strongly agreed.

Responses to item #7 indicated that the majority of parents (82.6% agree and strongly agree) believed vac- cines prevent some serious illnesses. The mode and median response was strongly agree, reflecting quite defini- tive opinions about this statement. The remaining responses were not sure, and there were no participants who disagreed. Parents were generally trusting of the information they received about shots (82.6%), with a mode and median response of agree for item #15. All but one participant (95.7% agree and strongly agree) reported being able to openly discuss their concerns with their child’s doc- tor. Were they to have another child today, 21 of the 23 participants

General Attitudes Sub-Domain Responses to the PACV Survey

items pertaining to the General Attitudes sub-domain (see Tables 1-3) were associated with nine survey entries. Item #5 asked parents to rate how sure the recommended vaccine schedule was good for their child. The majority of participants (73.9%) reported a score between 8 and 10, indicating non-hesitant responses. Item #17 asked the degree to which parents trusted their doctor, with 91.3% providing responses in the range from 8 to 10, indicating they trusted their healthcare provider. Item #6 asked for parents to agree with whether children were given too many shots than was good for them; the mode was not sure (52.2%), with a relatively symmetric distribution. Item #8 asked for opinions on whether it was better to develop immunity by becoming ill rather than

Notes: Response formats for items: 5 and 17 = response category on a 0 to 10 scale, with 0 being “not at all” and 10 being “com- pletely”; 6 to 8 and 15 to 16 = strongly agree/agree/not sure/disagree/strongly disagree; 13 = yes/no/don’t know; 14 = not at all hes- itant /not too hesitant/not sure/somewhat hesitant/very hesitant. *Non-adherent case.

Table 3. Parent Attitude about Childhood Vaccine (PACV) Survey Items within General Attitudes Sub-Domain

Number Description

Response Formats, Scoring, and Obtained Frequencies

0 to 5 2

6 to 7 1

8 to 10 0

5 How sure are you that following the recommended shot schedule is a good idea for your child?

2* 4 17

17 All things considered, how much do you trust your child’s doctor? 2 0 21* SA 2

A 2

NS 1

D 0

SD 0

6 Children get more shots than are good for them. 0 4* 12 5 2 8 It is better for my child to develop immunity by getting sick than to get a

shot. 1 4* 3 10 5

0 0 1 2 2 7 I believe that many of the illnesses that shots prevent are severe 12 7 4* 0 0 15 I trust the information I receive about shots. 6 13 2 2* 0 16 I am able to openly discuss my concerns about shots with my child’s

doctor. 12 10* 1 0 0

Y 0

N 2

DK 1

13 If you had another infant today, would you want him/her to get all the recommended shots?

21 1* 1

NAH 0

NTH 0

NS 1

SH 2

VH 2

14 Overall, how hesitant about childhood shots would you consider yourself to be?

8 10 0 5* 0

PEDIATRIC NURSING/January-February 2017/Vol. 43/No. 1 27

(91.3%) would want the child to receive all the recommended shots, one parent would not, and one was not sure. The final item asked parents to rate their overall hesitancy with respect to childhood vaccines; 24.8% were not hesitant, and 43.5% were not too hesitant, for a total of 78.3% reporting a non-hesitant response. The remaining five participants (21.7%) reported somewhat hesitant.

The non-adherent case per the PACV Survey reported trust in their child’s doctor and the ability to dis- cuss concerns about vaccines with their healthcare provider. However, the parent felt that the recommended vaccine schedule was not a good idea and mistrusted the information received about vaccines. The parent agreed that children get too many shots at one time and that developing immunity by getting sick was prefer-

Safety and Efficacy scale scores were broadly distributed, and relative- ly symmetrical, and the median and the mean were almost identical. General Attitudes score was right- skewed, with the majority of cases toward the low, non-hesitant, end-of- the-scale range. The median was lower than the mean, reflecting the influ- ence of the higher extreme scores on the calculation of the mean. The total score exhibited right skew, with more cases obtaining scores at the low end of the range.

Overall PACV Survey scores were analyzed (see Tables 4 and 5). The vast majority of participants (91.3%) fell in the not vaccine-resistant range. One case was classified as moderately vaccine-resistant, with a score of 57. Finally, the one non-adherent case had a PACV Survey score of 80, falling into the very vaccine-resistant range.

able to the vaccine although was not sure whether vaccines prevented some serious illnesses. Due to overall hesitation about vaccines, the parent stated the recommended vaccine schedule would not be followed if the family had another child in the future. Thus, PACV Survey responses provided by this participant were biased toward hesitant responses, as would be expected.

PACV Scale Scores The 15 items on the PACV Survey

were scored according to the standard instructions and were computed to show the distribution of scores within each area along with converted total PACV Survey scores and descriptive statistics. Converted scores may range from 0 to 100, with scores of 50 or above signifying vaccine-hesitant par- ents (Opel et al., 2011, 2013).

Table 4. Descriptive Statistics of Parent Attitude about Childhood Vaccine (PACV) Survey Sub-Domain and Total Scales

Scale Number of Items M Median SD Minimum Maximum Raw scores (Mean per iItem) Behavior 2 0.0870 0.0000 0.4170 0.0000 2.0000 Safety and efficacy 4 0.7609 0.7500 0.7090 0.0000 2.0000 General attitudes 9 0.2995 0.1111 0.3797 0.0000 1.4444 Total score 15 0.3942 0.2667 0.4114 0.0000 1.6000

Converted scores Total score 15 19.6522 13.0000 20.6719 0.0000 80.0000

Notes. Raw scale scores can range from 0 to 2, with higher values indicating greater hesitancy toward childhood vaccines. Table values are presented to 4 decimal places due to the small range of raw scores. The converted total score can range from 0 to 100.

Table 5. Kendall’s Taub Intercorrelations Between Parent Attitude about Childhood Vaccine (PACV)

Survey Scores and Demographic Characteristics Number Variable 1 2 3 4 5 6

PACV Scores 1 Total score — 2 Safety and efficacy 0.748* — 3 General attitudes 0.630* 0.296 —

Demographic Variables 4 Parent relationship to child 0.269 0.312 -0.092 — 5 Parent age 0.005 0.071 -0.039 0.281 — 6 Child firstborn -0.252 -0.342 -0.055 -0.087 -0.130 — 7 Number of children in household 0.221 0.320 0.031 0.055 0.136 -0.858*

Notes. Coding for demographic variables: parent relationship to child (1 = father, 2 = mother); parent age (1 = 18 to 24 years, 2 = 25 to 31 years, 3 = 32 to 38 years, 4 = 39+ years); child firstborn (1 = no, 2 = yes); number of children in household (1 = one, 2 = two, 3 = three). * p < 0.001 (2-tailed).

28 PEDIATRIC NURSING/January-February 2017/Vol. 43/No. 1

Association Between PACV Survey Scores and Demographic Variables

All demographic variables were either dichotomous or ordinal. Non- parametric correlations in the form of Kendall’s Tau-b were computed to eval- uate the associations between the vari- ables (see Tables 4 and 5). The two sub- domain scores of Safety and Efficacy and General Attitudes had a moderate positive correlation that was not statis- tically significant (Tau-b = 0.296). There were no statistically significant associations between any PACV Survey scores and demographic variables, although the small sample size influ- enced the obtained significance.

The largest coefficients in terms of absolute value were between Safety and Efficacy scores and the parent’s relationship to child, whether a child was firstborn, and the number of chil- dren in the household (all > 0.3) (see Figure 1). The sign of the coefficients indicated that mothers tended to pro- vide more vaccine-hesitant scores than fathers as pertained to safety and efficacy concerns. Parents of firstborn children had lower scores related to safety and efficacy, and were more vaccine-accepting than parents of two or three children.

having a shot was not agreed to be a good option for most parents. Further, parents generally believed shots may prevent some serious diseases. Overall, the largest proportion of parents reported being non-hesitant about childhood shots, agreed with the rec- ommended CDC schedule, and would want to follow the recommended schedule with another child.

No significant associations were found between PACV Survey scores and demographic variables, although the small sample size greatly impeded the power to detect statistically sig - nificant relationships. Nonetheless, trends based on noteworthy magni- tudes and signs of coefficients indicat- ed that safety and efficacy concerns tended to be rated higher and more vaccine-hesitant by mothers as com- pared to fathers, and by parents of two or more children as compared to parents of firstborn children.

Study Limitations The purpose of this study was to

examine the relationships between parental hesitancy toward childhood vaccines at birth, their demographic characteristics, and their adherence to the CDC-recommended vaccination schedule for their infants two months later. However, due to unexpected bar- riers having a negative impact on the study, data were only obtained from 23 parents of newborn children, and only one parent did not adhere to the rec- ommended CDC schedule. Therefore, formal comparisons bet ween adherent and non-adherent cases and between pre- and post-PACV Survey data were not possible. Accor dingly, the study scope was narrowed to a descriptive analysis of participants, their PACV Survey item responses, PACV Survey scores, and an analysis of the associa- tion between PACV Survey scores and demographic characteristics.

The length of study period had an impact on the validity of study findings. This time barrier impacted the sample size. In addition, the Disney measles outbreak erupted dur- ing the study period. Many news debates and discussions on the topic of vaccination were televised, which may have had an impact on the amount of families that were vaccine- hesitant. Further, families were over- whelmed with new office paperwork, often declining to participate in the evidence-based study.

The investigator recommends lengthening the study timeframe if

Discussion The PACV Survey consists of

three sub-domains. In terms of the Behavior domain, only the non- adherent case reported ever delaying or deciding not to have a child receive a shot. With regard to Safety and Efficacy, parents were uncertain about whether it was better to have fewer vaccines at the same time. Almost half of the parents reported being somewhat concerned with serious vaccine side effects. About a quarter stated some concern with both vac- cine safety and effectiveness, and these findings were similar to results by Glanz et al. (2013).

The General Attitudes domain touched on a number of topics. The sample of parents generally trusted the information they received about shots, trusted their doctor, and felt able to openly discuss concerns with the doctor. The result of provider trust was similar to the mixed method study by Glanz et al. (2013). Research subjects generally trusted the informa- tion they received about vaccines; however, this was in contrast to study data from Glanz et al. (2013) and Mills et al. (2005). Developing immunity by contracting the illness rather than

Figure 1. Boxplots Displaying the Distribution Parent Attitude about Childhood Vaccine (PACV) Survey Scores by Relationship to the Child and

Number of Children in the Household (1 or 2+)

Relationship Total ScoreGeneral AttitudesSafety & Efficacy

Mo.Fa.Mo.Fa.Mo.Fa.

2.0

1.5

1.0

0.5

0.0

1 2+

No. Children

Ra w S ca le S co re

Notes: Individual (diamonds) and mean (circles) symbols are also displayed. Behavior sub-domain scores are not shown due to almost constant variance. Fa. = father, Mo. = mother.

PEDIATRIC NURSING/January-February 2017/Vol. 43/No. 1 29

this study is repeated. The investiga- tor believes starting the study on new- borns at one month of age and com- pleting the study at two months of age would be less stressful for the fam- ilies involved in the study. In addi- tion, if the study had started in late spring through fall, the stress of implementing the study within the study location may have decreased, thereby enhancing support from stakeholders.

Implications for Nursing Study results may have an impact

on how pediatric practices choose to educate patients that are identified to be vaccine-hesitant. The findings are generalizable to other pediatric pri- mary care clinics in an upper social- economic area. The video can be incorporated into a practice’s meet the practice class or website for new families expecting a baby. The inter- vention may be expanded to the edu- cation of hesitant parents to adoles- cent vaccines.

Similar evidence-based research projects can be implemented within pediatric clinics in the state of Arizona and nationwide. The study directly impacts the goals of Healthy People 2020 by increasing parents’ awareness of vaccine-preventable dis- eases in the state of Arizona. The study also directly impacts the Arizona Department of Health Services action plan to address the increasing vaccine exemptions in the state of Arizona.

Conclusions In summary, the PACV Survey is a

valid tool to help identify vaccine-hes- itant parents; further, it reduces the time burden on healthcare pro viders and increases the number of times a parent is exposed to evidence-based vaccine information. Voice-over PowerPoint presentations may be a valuable option to educate vaccine- hesitant families while waiting to see their healthcare providers. The PowerPoint presentation assists in cor- recting misinformation on vaccines and does so in an efficient manner that can easily be implemented in pediatric clinics across the nation. This allows additional time for the healthcare provider to cover necessary anticipato- ry guidance and further gain parents’ trust and respect.

References Arizona Department of Health Services.

(2013a). Action plan to address increas- ing vaccine exemptions. Retrieved from http://azdhs.gov/documents/prepared ness/epidemiology-disease-control/ immunization/statistics-reports/action- plan-address-vaccine-exemptions.pdf

Arizona Department of Health Services. (2013b). Immunizations. Retrieved from http://azdhs.gov/documents/prepared- ness/epidemiology-disease-control/ immunization/newsletters/immunica tions/13-fall-immunications.pdf

Arizona Department of Health Services. (2014). Arizona kindergarten immuniza- tion coverage levels 2013-2014 school year. Retrieved from http://azdhs.gov/ documents/preparedness/epidemiolo gy- disease-control/immunization/statis tics- reports/kindergarten-coverage- 2013- 2014.pdf

Armstrong, E.P. (2007). Economic benefits and costs associated with target vacci- nations. Journal of Managed Care Pharmacy, 13(7), S12-S15.

Becker, M.H. (1974). The health belief model and personal health behavior. Thorofare, NJ: Charles B. Slack.

Birnbaum, M., Jacobs, E., Ralston-King, J., & Ernst, K. (2013). Correlates of high vac- cination exemption rates among kinder- gartens. Vaccine, 31, 750-756.

Centers for Disease Control and Prevention (CDC). (2012). National, state, and local area vaccination coverage among chil- dren aged 19-35 months – United States, 2011. Morbidity and Mortality Weekly Report, 61, 689-696.

Centers for Disease Control and Prevention (CDC). (2014). National, state, and local area vaccination coverage among chil- dren aged 19-35 months – United States, 2013. Morbidity and Mortality Weekly Report, 63, 741-748.

Centers for Disease Control and Prevention (CDC). (2015). Measles cases and out- breaks. Retrieved from http://www. cdc.gov/measles/cases-outbreaks.html

Centers for Disease Control and Prevention (CDC). (n.d.). For parents: Vaccines for your children. Retrieved from http:// www.cdc.gov/vaccines/parents

Children’s Hospital of Philadelphia. (2013). Vaccine safety. Retrieved from http:// vec.chop.edu/service/vaccine-educa tion-center/vaccine-safety

Committee on Practice and Ambulatory Medicine and Council on Community Pediatrics. (2010). Policy statement: Increasing immunization coverage. Pediatrics, 125, 1295-1304.

Cooper, L., Larson, H., & Katz, S. (2008). Protecting public trust in immunization. Pediatrics, 122(1), 1-5.

Dempsey, A., Schaffer, S., Singer, D., Butchart, A., Davis, M., & Freed, G. (2011). Alternative vaccination schedule preferences among parents of young children. Pediatrics, 128, 848-856.

Glanz, J., Wagner, N., Narwaney, K., Shoup, J., McClure, D., McCormick, E., & Daley, M. (2013). A mixed methods study of parental vaccine decision-mak- ing and parent-provider trust. Academic Pediatrics, 13, 481-488.

Institute for Vaccine Safety. (2012). Vaccine exemptions. Retrieved from http://www. vaccinesafety.edu/cc-exem.htm

Janz, N.K., & Becker, M.H. (1984). The health belief model: A decade later. Health Education Quarterly, 11(1), 1-47.

Kempe, A., Daley, M.F., McCauley, M.M., Crane, L.A., Suh, C.A., Kennedy, A.M., ... Dickinson, L.M. (2011). Prevalence of parental concerns about childhood vac- cines: The experience of primary care physicians. American Journal of Pre - ventive Medicine, 40(5), 548-555.

Koh, H. (2010). A 2020 vision for healthy peo- ple. The New England Journal of Medicine, 362, 1653-1656.

Lieu, T.A., McGuire, T., & Hinman, A.R. (2005). Overcoming economic barriers to the optimal use of vaccines. Health Affairs, 24(3), 666-679.

Mennito, S.H., & Darden, P.M. (2010). Impact of practice policies on pediatric immu- nization rate. Journal of Pediatrics, 156, 618-622.

Mills, E., Jadad, A., Ross, C., & Wilson, K. (2005). Systematic review of qualitative studies exploring parental beliefs and attitudes toward childhood vaccination identifies common barriers to vaccina- tion. Journal of Clinical Epidemiology, 58, 1081-1088.

National Committee for Quality Assurance. (2013). The state of health care quality 2013. Retrieved from https://www.ncqa. org/Portals/0/Newsroom/SOHC/2013/S OHC-web_version_report.pdf

Offit, P.A. (2011). Deadly choices: How the anti-vaccine movement threatens us all. New York, NY: Basic Books.

Opel, D., Taylor, J., Mangione-Smith, R., Solomon, C., Zhao, C., Catz, S., & Martin, D. (2011). Validity and reliability of a survey to identify vaccine hesitant parents. Vaccine, 29, 6598-6605.

Opel, D., Taylor, J., Zhou, C., Catz, S., Myaing, M., & Mangione-Smith, R. (2013). The relationship between parent attitudes about childhood vaccines survey scores and future child immunization status. A validation study. Pediatrics, 167, 1065- 1071.

Reiter, P., Stubbs, B., Panozzo, C., Whitesell, D., & Brewer, N. (2011). HPV and HPV vaccine education intervention: Effects on parents, healthcare staff, and school staff. American Association for Cancer Research, 20, 2354-2361.

Sadaf, A., Richards, J., Glanz, J., Salmon, D., & Omer, S. (2013). A systematic review of interventions for reducing parental vaccine refusal and vaccine hesitancy. Vaccine, 31, 4293-4304.

Smith, P., Kennedy, A., Wooten, K., Gust, D., & Pickering, L. (2006). Association bet - ween health care providers’ influence on parents who have concerns about vac- cine safety and vaccination coverage. Pediatrics, 118, e1287- e1292.

Spleen, A., Kluhsman, B., Clark, A., Dignan, M., & Lengerich, E. (2012). An increase in HPV related knowledge and vaccina- tion intent among parental and non parental caregivers of adolescent girls, age 9-17 years, in Appalachian Penn - sylvania. Journal of Cancer Education, 27, 312-319.

continued on page 34

34 PEDIATRIC NURSING/January-February 2017/Vol. 43/No. 1

Impacting Parental Vaccine Decision-Making continued from page 29

Stern, A., & Markel, H. (2005). The history of vaccines and immunization: Familiar pat- terns, new challenges. Health Affairs, 24, 616-621.

Voices for Vaccines. (n.d.). Tools. Retrieved from http://www.voicesforvaccines.org/ tools

Williams, S., Rothman, R., Offit, P., Schaffner, W., Sullivan, M., & Edwards, K. (2013). A randomized clinical trial to increase acceptance of childhood vaccines by vaccine hesitant parents: A pilot study. Academic Pediatrics, 13, 475-480.

Copyright of Pediatric Nursing is the property of Jannetti Publications, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.