AIM Adolescent Immunization Webinar Adolescent Health Beliefs and
AIM Adolescent Immunization Webinar: Adolescent Health Beliefs and Encouraging Provider Vaccination Recommendations April 25, 2017 1
UNITY Vision and Mission MISSION: Provide action-oriented leadership, innovation and education on preventive health and immunization for adolescents and young adults: ESTABLISH immunization as a central component of preventative health and as an investment in lifelong health. VISION Coverage is 90% or greater for all nationally recommended vaccines for adolescents and young adults ENGAGE parents, adolescents and young adults to embrace the value of immunization. DEVELOP healthcare providers as advocates that make strong recommendations for all nationally recommended vaccines. ENSURE easy access to and timely delivery of all recommended vaccines. 1
Substantial Gaps In Adolescent Vaccination HPV (1 st, Series), Men. ACWY Booster, and Flu 2015 Immunization Rates, United States 100 Estimated vaccine coverage (%) 90 86 80 Healthy People 2020 Goal 81 70 63 60 50 42 40 30 50 33 20 47 28 10 0 Tdapa ≥ 1 dose Men. ACWYb ≥ 1 dose Men. ACWY boosterc HPVd ≥ 1 dose, females HPV ≥ 3 doses, females HPV ≥ 1 dose, males HPV ≥ 3 doses, males Influenzae Vaccine Tdap = tetanus, diphtheria, acellular pertussis; b Men. ACWY = meningococcal conjugate vaccine; c Booster-dose rate based on 17 -year-olds; d HPV = human papillomavirus; e 2015 -2016 influenza season a MMWR. 2015; 64(29): 784 -792; http: //www. cdc. gov/flu/pdf/fluvaxview/2015 -16/nfid-coverage-2015 -16 -final. pdf www. unity 4 teenvax. org
Recommended Immunizations 11 -12 Years and 16 Years Vaccine is recommended for all children unless your doctor tells you that your child cannot safely receive the vaccine Vaccine is recommended for children not at increased risk but who wish to get the vaccine after speaking to a provider Vaccine is recommended for children with certain health or lifestyle conditions that put them at an increased risk for serious diseases Vaccine should be given if a child is catching up on missed vaccines https: //www. cdc. gov/vaccines/who/teens/downloads/parent-version-schedule-7 -18 yrs. pdf www. unity 4 teenvax. org 4
UNITY Members, Liaisons, and Participants www. unity 4 teenvax. org 2
Today’s Topics Beliefs on Adolescent Health and Immunization: Results From The Harris Poll of Teens, Parents and Healthcare Providers Judy Klein, President, UNITY Consortium Brief Discussion/Q&A Three Cs: Strong Provider Recommendations for Adolescent Vaccines Gregory Zimet, Ph. D, Professor of Pediatrics & Clinical Psychology, Indiana University School of Medicine Brief Discussion/Q&A www. unity 4 teenvax. org 6
Poll and Research Objectives Unity-sponsored Harris poll with parents, teens and healthcare providers to understand their views on health, prevention and immunization. Results used to educate and align parents, teens, and healthcare providers around the clear and certain value of immunization as a driver of adolescent and life long health
Topline U. S. Poll Results Methodology U. S. Poll fielded Sept-Oct 2016 20 minute, online, self-administered survey Participants Teens (n=506): split by teen’s age 13 -15/16 -18 & gender Parents (n=515): split by teen’s age 13 -15/16 -18 & gender Healthcare Providers (n=510): PCPs/Pediatricians (n=405) and Pharmacists (n=105) I 8
Unity Survey U. S. Results Overview Attitudes Towards Adolescent Preventive Health Adolescent Health – Roles and Responsibilities Vaccination –Roles and Responsibilities Vaccination I 10
Attitudes Towards Adolescent Preventive Health Teens are genuinely interested in living a healthy lifestyle and taking more responsibility for their health, more interested than HCPs and parents think Staying healthy is very or extremely important to virtually all teens and their parents More important General consensus between HCPs, parents and teens on what is important for teens staying healthy Keeping safe from STDs, avoiding alcohol/drugs/ smoking, getting enough sleep, eating healthy Getting all recommended vaccines, flu shots, seeing a doctor Less important 11
Adolescent Health – Roles and Responsibilities Teens believe… Teens are more responsible than their parents for: • Exercising • Managing stress • Maintaining good oral health • Avoiding alcohol/drugs/smoking • Getting enough sleep • Keeping safe from STDs • Taking good care of skin Parents are more responsible for: • Getting all recommended vaccines • Seeing a doctor regularly • Getting a flu shot I 12
Health Today Vs. Future Virtually all healthcare providers agree that many teens think things they do now will not have a big effect on their health in the future. Sizeable minorities of teens and parents share this belief Things I do now will not have a big effect on my health in the future (% Strongly/Somewhat agree) 93% 27% n=506 Teens 98% 38% n=515 Parents n=405 Physicians n=105 Pharmacists
Responsibility for Maintaining Good Health Nearly universally, doctors and teens believe that ultimately maintaining good health is the teens’ responsibility. While still a majority, parents are less likely to place the full burden on teens. 94% teens 63% parents 98% I feel like my health is my responsibility I feel that my (son/daughter)'s health is his/her responsibility Teens should be encouraged to assume more responsibility for their health HCPs
Adolescent Health – Roles and Responsibilities Almost all teens fully trust their HCPs for info about their health, but many don’t like talking to their HCPs and don’t visit HCPs if they feel healthy or see why they should • HCPs overwhelmingly agree that these misperceptions are common among teens I 15
Adolescent Health – Roles and Responsibilities The majority of HCPs, parents and teens agree that: • Teens need parents’ help to stay healthy • Teens and parents need to learn more about how to be healthy • Keeping teens healthy requires a coordinated/joint effort of parents, teens’ physicians and other HCPs • Parents are important to teens as it relates to their health • Most teens first turn to their parents for info about their health • Virtually all teens are comfortable asking and completely trust their parents on questions about their health • Only a minority of HCPs believe that teens are comfortable talking to parents about their health I 16
Vaccination Roles and Responsibilities • Teens, parents and HCPs believe that parents are and should be primarily responsible for kids getting all recommended vaccines • Teens rely on doctors and parents for information about vaccines, with parents most influencing the decision on whether to receive a vaccine; friends have some influence as well • Teens are not interested in having more say • Parents rely on doctors as their primary source of information about specific vaccines • Physicians think that parents have the most influence on whether their teens, particularly younger teens ages 13 -15, receive vaccinations I 17
Vaccination Physicians report that ~1/5 teens are not up to date on their vax Less than 2/3 of physicians have processes to remind teen patients about the next recommended vaccine Less than 1/2 have reminders in place for the missed vaccination Virtually all HCPs think teens and parents should better understand the benefits of vaccination • Virtually all HCPs say they take time to convince parents and teens to have teens vaccinated • Most HCPs think more materials are needed to help HCPs stay informed and to help HCPs discuss vaccinations with parents and teens I 18
Relevance of Vaccines There is a sizeable minority Teens and Parents who don’t understand how vaccines help teens. And half or more share some concerns about safety. HCPs believe… 98% Teens and Parents should better understand the benefits of vaccination Teens believe… Parents believe… 57% 47% I have some concerns about the safety of vaccinations What I have read on social media has me concerned about the safety of some vaccines 57% 45% 23% 34% Vaccines are for babies, not as important for teens I don't know how being vaccinated helps me 23%
Take-Aways and Implications for HCPs “Shared Responsibility for Life Long Health” Virtually all healthcare providers agree that many teens think the things they do now will not have a big effect on their health in the future. In reality, the habits adopted at a young age can have life-long effects. Diet, activity level, risky behavior choices, and a willingness to embrace preventive health, can all impact adolescents well into adulthood. Almost all teens fully trust their HCPs for information about their health, but they don’t necessarily see their doctor regularly enough to learn about their health, and when they do engage in conversations, it rarely goes beyond the typical teenage one word answers. Nearly all healthcare professionals believe teens should be encouraged to assume more responsibility for their health. Between trusting their doctor and teens reliance on their parents to stay healthy, a coordinated effort of parents, and HCPs can make the difference. Taking time now to discuss why the things we do now, like getting immunized, can have a life long-impact, can make a permanent difference in how these teens grow into adults and caregivers for future generations. 20
Messages for Healthcare Providers to Parents and Teens Healthcare providers should advocate to parents AND teens the reason why preventative health and vaccinations are critical for life long health > 90% of HCPs believe teens think the things they do now will not have a big effect on their health in the future Be blunt in the need for preventative health including vaccination. Address misperceptions and how avoidance can have long-term implications Vaccine safety concerns on social media still plague parents’ and teens’ perceptions. Reinforce the safety of and need for vaccines and the danger in skipping or delaying adolescent immunizations 21
Take-Aways and Implications for Parents/Teens “Shared Responsibility for Life Long Health” Parents and teenagers believe teens are genuinely interested in being healthy; with teen emphasis on general lifestyle goals like staying safe from STDs, good oral health, and avoiding drugs/alcohol. However, most teens are not interested in having more say in whether or not to get vaccinated. Maybe this is because …. they don’t understand why immunization is important or they have safety concerns based on what they read on social media. Regardless of the reason, if teens and parents aren’t taking the shared responsibility to learn preventative health habits, and to understand why vaccines are important, these teens are less likely to bring healthy habits into adulthood. Teens consistently look to their parents for advice. There is a widely recognized need for parents to stay involved in keeping their kids healthy so that they can lay the groundwork for a life long healthy lifestyle. 22
Messages for Parents to Teens Support teens in leading the way to vaccination, but also give them the information they need to understand why vaccinations are important 87% of parents say that they are more responsible for their teen getting all recommended vaccines Preventative health measures should become a habit. Let teens know why vaccines are important now and for their future Parents are not familiar with the vaccines recommended for teens Trust your healthcare provider and the experts - be in the know about the safety and benefit of vaccines and share that knowledge with your teen Many parents believe life is too busy to see the doctor when teens are healthy Find a convenient and trusted place for teens seeking general health information and guidance, including vaccines Parents pause when you hear health news that impacts teens (meningitis outbreaks) Take action to educate teens on what they can do to limit their risk 23
Discussion How can these Poll results support your efforts to increase vaccination coverage? www. unity 4 teenvax. org 24
Q&A www. unity 4 teenvax. org 25
Three Cs Objectives • To review the Three Cs provider recommendation – confident, concise, and consistent – as a potential tool to improve routine vaccination coverage for adolescent vaccines • To provide a simple framework and tools for the use of a Three Cs recommendation including FAQs and Motivational Interviewing techniques www. unity 4 teenvax. org 26
Routine Recommendation of Adolescent Vaccines 11/12 Years Old 16 Years Old Same day vaccination of: Tdap Men. ACWY HPV 1 of 2 Flu (in season) 6 -12 mos Same day vaccination of: Men. ACWY Booster Men B* Men. B-4 C 1 of 2 Men. B-FHbp 1 of 2 >1 mo HPV 2 of 2 Reflects new ACIP dosing guidelines for routine administration of HPV and Men. B; *Men. B -FHbp: Trumenba (Pfizer); Men. B-4 C: Bexsero (Novartis); For persons at increased risk for meningococcal disease and during serogroup B outbreaks, administer 3 doses of Men. B-FHbp administered at 0, 1 -2, and 6 months Flu (in season) 6 mos Men B 2 of 2 www. unity 4 teenvax. org 27
The Three Cs Approach Focuses On The In-Office, Provider Recommendation Pre-Visit/ Visit Arrival • Knowledge/en gagement/exp ectations − Parents − Adolescents Vaccination Recommendation • Provider recommendation Vaccination Discussion • FAQs • Discussion aligned to parental disposition Vaccination Action • Same visit administration vs. delay • Vaccine series completion − Providers • EHR prompts • Standing Orders Followup • Reminder/recall − Preventive visits − Vaccination visits (series completion) Three Cs Recommendation Confident, Concise, Consistent (11, 12, 16 year olds’ visits) www. unity 4 teenvax. org 28
Three Cs Approach Confident, Concise, Consistent Provider Recommendation • Presumptive • Bundled and Equal • Same Day Vaccination UNITY Consortium Provider Tools • FAQs • Motivational Interviewing www. unity 4 teenvax. org 29
Delivering A Three Cs Recommendation ASSUME ‘acceptor’ status for all parents DELIVER Three Cs Recommendation • Presumptive • Bundled and equal • Same day vaccination Consent? VACCINATE! Three Cs: Confident, Concise, Consistent www. unity 4 teenvax. org
Anatomy Of A Three Cs Recommendation Presumptive • HOW the recommendation is initiated • Assumes that parent will consent • Recommends with confidence and conviction Presumptive Language 11 -12 year old visit: “Our sixth grade vaccines that we do, there are three… 11 -12 year old visit: “He's due for his 11 -year-old shots. We didn’t do them last time he was here for his check up because he was sick last time, but he is due for three vaccines. 16 year old visit: “Right now, today, we're talking about your vaccines, and you are due for the two meningitis shots” Three Cs QI Study, 2016 www. unity 4 teenvax. org 31
Value of a Presumptive Recommendation Multiple studies suggest that a presumptive recommendation leads to a higher rate of vaccination Opel, D. et al, Pediatrics, 2013: 132: 1– 10; Brewer, N. et al, Pediatrics, Published online December 2016, /10. 1542 peds. 2016 -1764 www. unity 4 teenvax. org 32
Anatomy Of A Three Cs Recommendation Bundled, Equal • HOW the recommendation is framed • Recommend all ACIP-recommended vaccines for that age (11/12, 16 years old) equally Bundled and Equal Language 11 -12 year old visit: “Our sixth grade vaccines that we do, there are three, and it's the Tdap, which is tetanus, diphtheria, pertussis. The other one is Gardasil, or HPV, and that one protects against cancer, and then the third one is meningitis, and that is a brain infection that we want to prevent. ” 11 -12 year old visit: “He is due for three vaccines. Actually we can do four today. So the three he's normally due for, he is due for meningitis, the HPV and the Tdap, and we can also do the flu vaccine today. ” 16 year old visit: “What you are due for today, I'm sure you're due for the two meningitis shots” Three Cs QI Study, 2016 www. unity 4 teenvax. org 33
Anatomy Of A Three Cs Recommendation Unbundled, Unequal Language Unbundled and Unequal Language “There are some required immunizations, and there is also a couple of immunizations we like to give just for general health and benefit” ✗ “One is your tetanus vaccine that is required for school, and then the HPV vaccine. That is kind of important…And then the other one is the meningitis vaccine, which is not required for school here, but in many states it is a requirement for middle school. It is a really important vaccine. It's not something that you kind of ignore. ” Three Cs QI Study, 2016 www. unity 4 teenvax. org 34
Anatomy Of A Three Cs Recommendation Same Day Vaccination • HOW the recommendation is offered • Administer all recommended vaccines at this office visit Same Day Vaccination Language • “He is going to be entering seventh grade…. So there are several shots that we give at this time. ” • So he'll get the first dose today and comes back in x months for the second dose…” • “You will get one shot of each today. ” Offering Delay Can Lead to Non-Vaccination • “You obviously do not have to do all of them today. ” • “It’s up to you. You can do them all now or you can wait. ” Three Cs QI Study, 2016; UNITY www. unity 4 teenvax. org 35
11 -12 YEARS Today you are due for three shots – Tdap, HPV, and meningitis. These shots are all important because they protect you from serious diseases that could make you very sick. You will get one shot of each today. We will have you come back for the final HPV shot in 6 months. 16 YEARS Three Cs Recommendations Today you are due for two shots that can protect you from meningitis, a rare but serious brain infection. There are two different vaccines because they protect you from different types of meningitis infections. All meningitis can lead to serious illness or even death so I want to protect you from as many types as I can. The first vaccine is a single shot at this visit. With the second vaccine, you will get a first dose today and then we’ll schedule you to come back for one additional shot. UNITY Consortium www. unity 4 teenvax. org 36
Giving Confident and Concise Answers (FAQs) ASSUME ‘acceptor’ status for all parents DELIVER Three Cs Recommendation • Presumptive • Bundled and equal • Same day vaccination Consent? VACCINATE! Questions? CONVEY confident and concise answers Three Cs: Confident, Concise, Consistent FAQ Topics Urgency/Timing Safety Efficacy Shotphobia School Requirements Multiple Doses Cost Advice Tdap HPV Meningitis www. unity 4 teenvax. org
FAQ Resources Three Cs Recommendation Language and FAQs www. unity 4 teenvax. org/unity-projects CDC FAQs (HPV) www. cdc. gov/vaccines/who/teens/for-hcp-tipsheet-hpv. pdf www. unity 4 teenvax. org
FAQ Examples School Requirements Urgency/Timing Safety Efficacy Shotphobia School Requirements Multiple Doses Cost Advice Tdap HPV Meningitis UNITY Consortium Q. Which vaccines are required for school (or sports)? I think that I only want to only get those today. A. While there may be a subset of vaccines required for school entry, I recommend all of these vaccines based on expert recommendations from doctors and scientists and what is best for your health. I strongly recommend that you get all of the vaccines today. www. unity 4 teenvax. org
Parental Disposition Framework Unquestioning Acceptor Cautious Acceptor Hesitant Late or Selective Vaccinator Refuser Three Cs Recommendation Answer Questions Motivational Interviewing Reassess Definitions of Parental Disposition from Leask, J. et al, BMC Pediatric 2012: 154, DOI: 10. 1186/1471 -2431 -12154; University of Colorado School of Public Health, Behavioral Health and Wellness Program Vaccinate Arrange Follow-Up www. unity 4 teenvax. org
Parental Disposition Majority Of Parents Are “Acceptors” <2% Unquestioning Acceptor 2 -27% Cautious Acceptor 30 -40% Hesitant 20 -30% 25 -35% Leask, J. et al, BMC Pediatric 2012: 154, DOI: 10. 1186/1471 -2431 -12 -154 Late or Selective Vaccinator Refuser 43
Parental Disposition Framework Unquestioning Acceptor Cautious Acceptor Hesitant Late or Selective Vaccinator Refuser Three Cs Recommendation Answer Questions Motivational Interviewing Reassess Definitions of Parental Disposition from Leask, J. et al, BMC Pediatric 2012: 154, DOI: 10. 1186/1471 -2431 -12154; University of Colorado School of Public Health, Behavioral Health and Wellness Program Vaccinate Arrange Follow-Up www. unity 4 teenvax. org
Motivational Interviewing The Key To MI Is The Right “Heart” Set Partnership Active collaboration Acceptance Non-judgmental Compassion Focus on well-being Evocation Strengths and resources University of Colorado School of Public Health, Behavioral Health and Wellness Program www. unity 4 teenvax. org
Motivational Interviewing Using OARS University of Colorado School of Public Health, Behavioral Health and Wellness Program www. unity 4 teenvax. org
Motivational Interviewing Tools 1. Invite parent/adolescent (P/A) to talk about vax 2. Encourage discussion of the change (pros) 3. Elicit how the P/A thinks and feels about vax 4. Use empathic listening statements when P/A talks about vax 5. Acknowledge challenges about vax that P/A faces 6. Provide information that is sensitive to P/A concerns 7. Actively convey respect for P/A choice 8. Exchange ideas with P/A about how to move forward toward acceptance University of Colorado School of Public Health, Behavioral Health and Wellness Program www. unity 4 teenvax. org
Motivational Interviewing What It Sounds Like Invites parent/adolescent to talk about vaccination What are your concerns about the vaccine? ” How can I better help you to understand the value of vaccinating? ” Encourages discussion of the change (pros) What benefits do you see in vaccinating? Why did you choose a 3 on the importance scale and not a lower number? ” (when using scale) Elicits how the parent/adolescent thinks and feels about vax Tell me what you have heard about the side effects of the vaccine. What have you heard from the school? Uses empathic listening You are anxious because you’ve read some pretty scary stuff on the Internet. You’re worried about getting three shots at a time. Making the right decision is very important to you. www. unity 4 teenvax. org 49
Motivational Interviewing What It Sounds Like Acknowledges challenges I hear your concern about him being able to play softball tonight. Getting time off work to come in for the next HPV shot will be a challenge for you. Provides information that is sensitive to parent/adolescent concerns You’ve mention two main concerns. Would it be alright with you if we talk about each one and then see what you think? Actively conveys respect for parent/adolescent choices I’ve shared my view about why this is an important vaccine but in the end this is a decision only you can make. Exchange ideas on how to move forward I have some information/ideas that might be helpful to you in making this decision. May I share them with you? www. unity 4 teenvax. org 50
Three Cs Recommendation Checklist 11 -12 Year and 16 Year Olds ü Presumptive recommendation for ALL ACIP-recommended vaccines for the age-based visit ü Vaccines presented in bundled and equal manner ü Recommendation for same day vaccination ü Accurate and concise responses to parental questions, if any ü Identification of parent/adolescent disposition, particularly ‘cautious acceptor’ vs. ‘hesitant’ ü Tailored conversation to parent/adolescent disposition ü Motivational interviewing tools for ‘hesitant’ and ‘refusing’ parents/adolescents UNITY Consortium www. unity 4 teenvax. org 51
Three Cs “Toolkit” Three Cs Rationale Three Cs Vignettes and Motivational Interviewing 0. 75 AMA PRA Category 1 Credits Vignettes/MI Worksheet Three Cs Recommendation Language and FAQs Parental Disposition and Motivational Interviewing for Hesitant or Refusing Parents Resources available at www. unity 4 teenvax. org/unity-projects 52
Summary • Providers are key to improving vaccination coverage for adolescents • A “strong” recommendation – confident, concise, and consistent (Three Cs) – can often lead to parental consent and same day vaccination • A Three Cs recommendation can be successful with the vast majority of parents • For those parents that are truly hesitant, providers can apply simple Motivational Interviewing tools to collaborate with parents and increase a parent’s motivation to change www. unity 4 teenvax. org 53
How To Support Three Cs ADOPTion! Assess current behaviors Determine what changes to make initially, then sequence Observe impact and reactions Practice and routinize Teach, train, and tell others www. unity 4 teenvax. org 54
Discussion • How can the Three Cs resources support your day-to-day activities? • How can UNITY support your stakeholders in their efforts to improve adolescent vaccination? www. unity 4 teenvax. org 55
Q&A www. unity 4 teenvax. org 56
AIM Adolescent Immunization Webinar: Adolescent Health Beliefs and Encouraging Provider Vaccination Recommendations April 25, 2017 57
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