Lab 1: The Ecological Model

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Lab 1: The Ecological Model Name(s): Anonymous Brief Description of Behavior: Influenza is a contagious viral respiratory illness which causes mild to severe disease, including symptoms of fever, cough, sore throat, runny nose, muscle aches, and fatigue. Some people, such as children and individuals with chronic medical conditions like asthma, are at high risk of complications from influenza infection. These complications can include bacterial pneumonia, ear infections, sinus infections, dehydration, and even death. The best prevention is annual vaccination (CDC, 2011). Parents in the United States are exposed to pros and cons of vaccination and are awash in propaganda from both sides of this issue. A growing minority of parents are choosing not to vaccinate their children, believing that the risks of the influenza vaccine outweigh the benefits. The CDC recommends that all children and adults six months and older receive vaccinations annually (CDC, 2011). Children from birth through age five are at especially high risk of serious flu-related complications (CDC, 2011). Considering the high transmission rate and potential severity of influenza in children in the U.S., we believe that getting children vaccinated against influenza is an important health behavior of parents. Our targeted behavior is having parents in Baltimore, Maryland get their children aged six months through six years vaccinated against influenza. Ecological Model Worksheet (30 points)

LEVEL Health Behavior Issue: … Intrapersonal: Issues of personal characteristics, beliefs, knowledge, attitudes, etc.

● Knowledge about vaccines ● Beliefs that vaccines are effective at preventing the disease or beliefs that vaccines can actually

cause the disease ● Beliefs that vaccines may put children at risk for other medical conditions (e.g. autism)

(DeStefano, 2001) ● Positive and negative experiences with vaccinations in the past (child has received other types of

vaccines or the influenza vaccine previously) ● Knowledge about influenza and the consequences of the infection ● Belief that the flu is/is not risky ● Belief that their children are at risk or not for being infected by the influenza virus ● Ability to differentiate between symptoms of flu versus other viral illnesses (which can influence

both a parent’s belief that flu is/is not risky (e.g. if a child has a upper respiratory infection from

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which he easily recovers and the parent believes that their child had the flu, they may not think that the flu is severe and may not take their child to get vaccinated) and that the vaccine is actually effective at preventing disease (e.g. if a child is vaccinated and still gets an upper respiratory infection, the parent may believe that the vaccine was not effective and not get their child vaccinated next year)

● Belief that bringing a child in for regular health care visits is important ● Concern that the possible immediate consequences of the vaccine outweigh the benefits (e.g. upset

children and possible post-vaccination fever and irritability) ● Having a child with a disease that limits their ability to receive the vaccine or certain forms of the

vaccine (e.g. if a child is sick it is recommended that parents wait until the child is better to have him vaccinated--parent may not want to return to their health care provider a second time; if a child has asthma, he cannot get the live-attenuated intranasal mist form of the vaccine, and parents may not want their child to receive the injection form or the injection form may not be available at all provider visits)

● Economic status of parents and their ability to pay for/access insurance or pay for the vaccine out of pocket

Interpersonal: Influence of social networks including families, friends, peers

● Beliefs of friends regarding importance of vaccinations (other parents in your neighborhood, school district, or social network have had their children vaccinated or not) (Rao, et al., 2007)

● Adverse events that other people in your network have experienced regarding vaccination (possibly leading to beliefs among friends that vaccination causes influenza or other medical conditions)

● Information available on social networking sites (e.g. Facebook groups--Parents and Others Against Vaccinations (http://www.facebook.com/groups/298427692661/) and VACCINE (http://www.facebook.com/groups/202729753137755/))

Institutional, Organizational: Roles of service providers, agencies, social institutions, etc.

● Access to healthcare ● Service providers beliefs in the importance/urgency of vaccination (physicians advocating for the

vaccine) ● Providers’ educational level and knowledge of the vaccine ● Ability of people to make appointments with their health care provider/have easy access to

vaccinations ● Convenience of vaccination locations (can parents go to pharmacies, grocery stores, or schools to

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have their child vaccinated; will they have to or be able to take time off of work) ● Transportation options and cost (can parents access health care easily) ● Schools encouraging vaccination ● Religious influences discouraging vaccination (Grabenstein, 2003) ● Educational/public health campaigns encouraging vaccination

Community: Norms, structure, politics, economic status

● Beliefs of influential leaders in the community about vaccines (e.g. Bill Maher stating that “people who get flu shots are idiots” (Parker-Pope, 2009); Michele Bachmann claiming that the Gardasil vaccine causes mental retardation (Hughes, 2011); Jenny McCarthy advocating against vaccination because of her belief that vaccines cause autism (Kluger, 2009))

● Presence of many children in the community who are/are not vaccinated ● Socio-economic status of the community (which likely influences many of the

institutional/organizational factors such as availability of health care, transportation, and convenience of vaccination locations)

Policy: Impact of laws, regulations, policies, decision makers, etc.

● Federal funding for programs to make vaccines available to families who may not be able to afford them (Vaccines for Children program)

● Funding for vaccine development (to ensure that new influenza vaccines are produced each year) ● Funding for vaccine manufacturing (to ensure that vaccines are made in a timely manner and that

enough of the vaccine is made to meet demands; if vaccines are not initially available when parents bring their children to health care providers to be vaccinated, parents may not return for a second visit once they become available or may never be able to access them if supply is extremely low)

● Lack of regulations for vaccine distribution (currently the CDC only makes recommendations to private sector manufacturers for distribution making it difficult to ensure that all health care provider types receive vaccines in a comparable time frame)

● Local governments not requiring school-aged children to be vaccinated against influenza

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Conclusions: The significant number of parents who choose not to immunize their children against influenza causes vaccination rates to remain suboptimal (Omer, 2009). Despite extensive efforts to improve the rates of immunization, the barriers to vaccination continue to be a challenge. The variables that determine whether parents vaccinate are interdependent across the ecological model proposed above. Consequently, prioritizing public health interventions is a complex endeavor that requires us to think across all ecological levels to establish where limited funding might make the greatest impact. Taking into account the multitude of factors listed above allows us to focus our efforts towards specific concerns and obstacles. A perfect intervention would encompass several ecological levels; therefore we feel our resources would be best used on a ‘macro-scale’, so as to reach the most people. The three ecological levels we believe influence parents the most and where we could make a measurable difference in immunization rates are (1) within the realm of policy, (2) within the organizations and institutions that parents are involved in and (3) within the community environment that they are surrounded by constantly. At the policy level, action should be taken to make the cost and availability more equitable, perhaps subsidizing influenza vaccine for all children 18 years and younger. At the institutional level, the vaccine could be administered in schools, providing easy access to the vaccine for families with school-aged children. Finally, at the community level, educational campaigns to increasing awareness of policy changes are key to their success. Such campaigns should aim to incorporate influential community leaders and, in addition to informing the public about vaccination requirements, should also provide information about controversial issues in an equal and unbiased way. As long as the influenza vaccine remains non-compulsory, convincing parents to vaccinate their children will be a struggle. Fortunately, recognizing that issues are ecologically intertwined provides numerous points of intervention. [This sample lab has a well-defined problem among a specific population. Good and adequate examples of factors at each level are provided, and the factors are actually appropriate to that level. The conclusion intelligently argues for a particular level of intervention. References are provided to back up all information and again, give the work more specificity to a particular setting.] References: Centers for Disease Control and Prevention. (2011). Key Facts about Influenza (Flu) & Flu Vaccine. Accessed 01 Feb 2012. Available from http://www.cdc.gov/flu/keyfacts.htm. DeStefano F. (2001). Vaccines and Autism. The Pediatric Infectious Disease Journal, 20(9), 887-888. Grabenstein J. (2003). Where Medicine and Religion Intersect. The Annals of Pharmacotherapy, 37(9), 1338-1339. Hughes SA. (2011). Michele Bachmann’s HPV claims just latest in Gardasil debate. The Washington Post. Accessed 01 Feb 2012. Available from

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http://www.washingtonpost.com/blogs/blogpost/post/michele-bachmanns-hpv-claims-just-latest- in-gardasil-debate/2011/09/14/gIQA9FjESK_blog.html. Kluger J. (2009). Jenny McCarthy on Autism and Vaccines. Time. Accessed 01 Feb 2012. Available from http://www.time.com/time/health/article/0,8599,1888718,00.html. Kraut A, Graff L, and McLean D. (2011). Behavioral Change with Influenza Vaccination: Factors Influencing Increased Uptake of the Pandemic H1N1 versus Seasonal Influenza Vaccine in Health Care Personnel. Vaccine, 29(46), 8357-8363.

Omer S, and Frew P. Acceptance of Pandemic 2009 Influenza A (H1N1) Vaccine in a Minority Population: Determinants and Potential Points of Intervention. Pediatrics, 127(Suppl 1), S113- 119. Parker-Pope, T. (2009). Bill Maher vs. the Flu Vaccine. The New York Times. Accessed 01 Feb 2012. Available from http://well.blogs.nytimes.com/2009/10/13/bill-maher-vs-the-flu-vaccine/. Rao N, Mobius M, and Rosenblat T. (2007). Social Networks & Vaccination Decisions. Research Center for Behavioral Economics & Decision Making. Web. Accessed 01 Feb 2012. Available: http://www.bos.frb.org/economic/wp/wp2007/wp0712.pdf.