V A C C I N E H E S I TA N C Y :

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1 V A C C I N E H E S I TA N C Y : T H E R O L E O F C O N V E N I E N C E T H E O R E T I C A L A S P E C T S A N D I S S U E S I N C A N A D A S H A N N O N M A C D O N A L D P H D, RN U N I V E R S I T Y O F A L B E R TA F A C U LT Y O F N U R S I N G

2 OUTLINE What is vaccine hesitancy and how does convenience fit in? What convenience issues influence vaccine hesitancy and uptake in Canada? What can we do to improve the convenience of vaccination?

3 VACCINE HESITANCY refers to reluctance to receive recommended vaccination because of concerns and doubts about vaccines that may or may not lead to delayed vaccination or refusal of one, many or all vaccines Dubé et al. for CIRN, 2016 Adamant refusers Uncertain refusers Delayers & Selective immunizers Cautious acceptors & Regretters Confident acceptors

4 VACCINE HESITANCY IS INFLUENCED BY: Complacency - do not perceive the vaccine as a necessity Confidence - lack of trust in vaccine/provider/policy-maker Convenience - physical availability, geographic accessibility, affordability, ability to understand (language and literacy), and delivery at a time and place and within a cultural context that is convenient Report of the Sage Working Group on Vaccine Hesitancy, 2014

5 SO HOW DOES CONVENIENCE RELATE TO VACCINE HESITANCY? Complacency Confidence Convenience Vaccine hesitancy Vaccine uptake Convenience

6 Demand Supply Vaccine uptake Complacency Confidence Convenience Report of the Sage Working Group on Vaccine Hesitancy, 2014; Larson, 2013

7 HOWEVER Convenience for one person may not be convenience for another person Convenience may be a matter of perception/subjectivity

8 CONVENIENCE DOES NOT TRUMP ALL Convenience Quality

9 W H AT C O N V E N I E N C E I S S U E S I N F L U E N C E V A C C I N E U P TA K E I N C A N A D A?

10 1. CONVENIENCE BARRIERS SPECIFIC TO VULNERABLE POPULATIONS Immigrant populations Indigenous people Families facing competing priorities

11 1. CONVENIENCE BARRIERS SPECIFIC TO VULNERABLE POPULATIONS Immigrant populations Indigenous people Families facing competing priorities

12 FAMILIES WITH MULTIPLE COMPETING PRIORITIES theagendadaily.com youcanmoveyourself.com everydaylife.globalpost.com Low income Housing insecurity No time Lack of social support Scheduling conflicts

13 Are families with multiple competing priorities more likely to start, but not finish, the infant vaccine schedule? And what are the characteristics of those families? Bell, Simmonds, MacDonald Exploring the heterogeneity among partially vaccinated children in a population-based cohort [Alberta]

14 Adj. Odds Ratio Influence of single parent status 2 Incomplete vs. Complete Reference= Married 1.58 ( ) 1 Not Married 0.5 Bell, Simmonds, MacDonald Exploring the heterogeneity among partially vaccinated children in a population-based cohort [Alberta]

15 Adj. Odds Ratio Influence of family size Incomplete vs. Complete Reference= 1 st Child ( ) 1.98 ( ) 3.24 ( ) 2nd Child 3rd Child >=4th Child 0.5 Bell, Simmonds, MacDonald, 2015 [Alberta] Similar result found in Hilderman et al.,2011 [Manitoba]

16 Adj. Odds Ratio Influence of multiple household moves 4 Incomplete vs. Complete Reference= No moves ( ) 1.35 ( ) 1.69 ( ) 1 One Move Two Moves >=Three Moves 0.5 Bell, Simmonds, MacDonald, 2015 [Alberta]

17 On top of those competing priorities, we add

18 2. INFLUENCE OF GEOGRAPHY MMR vaccine coverage by age 2 years in Alberta, 2015 IHDA

19 Time to Immunization- MMR vaccine- 132 local geographic areas in Alberta 2014 Dover Methods in immunization surveillance

20 Time to Immunization- MMR vaccine- 132 local geographic areas in Alberta 2014 Dover Methods in immunization surveillance

21 3. COST STILL AN ISSUE IN CANADA Out of pocket costs, e.g. travel to clinic Privately funded vaccines Morin, Lemaître, Farrands, et al Maternal knowledge, attitudes and beliefs regarding gastroenteritis and rotavirus vaccine before implementing vaccination program [Québec] Dubé, Gilc, Sauvageau, et al Clinicians opinions on new vaccination programs implementation [pan-canadian]

22 % of Alberta children receiving 1 dose of privately-funded rotavirus vaccine ( ) 4.50% 4.00% 3.50% 3.00% 2.50% 2.00% 1.50% 1.00% 0.50% 0.00% 3.83% 2.84% 3.05% 2.35% 1.33% Q1 Q2 Q3 Q4 Q5 Income quintile MacDonald, Bell, Simmonds Coverage and determinants of uptake for privately funded rotavirus vaccine in a Canadian birth cohort, [Alberta]

23 Profile of those less likely to purchase RV vaccine Young mothers Unmarried mothers Low income First Nations Rural residence 23

24 4. INCONVENIENCE DUE TO INADEQUATE INFRASTRUCTURE a. Delay in accessing services due to inadequate delivery capacity There s a disease outbreak! Quick, get your child immunized! What do you mean I can t get an appointment until 10 weeks from now!

25 4. INCONVENIENCE DUE TO INADEQUATE INFRASTRUCTURE b. Missed opportunities due to inadequate provider knowledge I can t vaccinate your child because they had a reaction to a previous vaccine This is really too many needles for a little baby to get in one day. Bring her back next week for the rest of them. You ll have to come back next week because your child has a cold todayry

26 4. INCONVENIENCE DUE TO INADEQUATE INFRASTRUCTURE c. Missed opportunities due to inadequate access to immunization records

27 * Provinces with an immunization information system (IIS) with reminder/recall functionality * * * * * Immunization Information Systems in Canada: Canadian Immunization Research Network (CIRN) Coverage Team (under review) 27

28 S T R AT E G I E S T O I M P R O V E T H E C O N V E N I E N C E O F V A C C I N AT I O N

29 Make the healthy choice the easy choice

30 STRATEGIES TO IMPROVE CONVENIENCE OF VACCINATION Immunization information systems* Reminders and recalls* School programs* Daycare programs* Home visits* Provider incentives Expanded availability of services Alternate providers and/or settings Reducing out-of-pocket costs* Opportunistic vaccination through standing orders* * Sufficient evidence to be a recommended intervention by The Community Preventive Services Task Force

31 STRATEGIES TO IMPROVE CONVENIENCE OF VACCINATION Immunization information systems* Reminders and recalls* School programs* Daycare programs* Home visits* Provider incentives Expanded availability of services Alternate providers and/or settings Reducing out-of-pocket costs* Opportunistic vaccination through standing orders* * Sufficient evidence to be a recommended intervention by The Community Preventive Services Task Force

32 Strategy 1 IMMUNIZATION INFORMATION SYSTEMS (ISS) 1.Facilitate vaccine management 2. Inform assessment of vaccination coverage 3.Guide public health responses to outbreaks 4. Permit interventions such as client reminders/recalls and provider reminders 5. Enable determination of client vaccination status to guide decisions by clinicians, health departments, and schools Increasing Appropriate Vaccination: Immunization Information Systems

33 MOBILE APPS

34 Strategy 2 REMINDERS & RECALLS Hi, I m calling to remind you of your dental appointment tomorrow But remembering your child s immunization appointment is entirely up to you.

35 LOTS OF EVIDENCE THAT IT WORKS Reminders are effective for: Odd Ratio 95% CI Childhood vaccines Childhood influenza vaccines Adult pneumo, tetanus, & Hep B vaccines Adult influenza vaccines Jacobson & Szilagyi. Cochrane review of Patient reminder and patient recall systems to improve immunization rates, 2005 Phone call reminders increased MMR coverage from 67% to 74% over one year across all income groups, compared to a 3% improvement in the control region Lemstra et al effectiveness of telephone reminders and home visits to improve MMR immunization coverage rates in children [Saskatchewan]

36 HOWEVER Recalls and reminders are a lot of work and the more effective measures are often more labour intensive and time consuming. Pereira et al Barriers to the use of reminder/recall interventions for immunizations: a systematic review Provincial privacy legislation is often an impediment to establishing functional registries and applying technology for reminders and recalls Compton, 2015

37 Strategy 3 SCHOOL PROGRAMS For school-age vaccine doses, e.g. HPV, influenza Although an individual s interface with their primary care provider remains an important source of widely trusted vaccine information, a broader range of school-based delivery clinics may be more efficient and expansive in reach Ministry of Health and Long-Term Care Immunization: Annual Report of the Office of the Auditor General of Ontario.

38 How effective are school programs?

39 Proportion of Grade 5 girls completing HPV vaccine, by school type and SES category (Calgary, Alberta, ) Musto et al Social equity in HPV vaccination: a natural experiment in Calgary Canada

40 OTHER IMPORTANT STRATEGIES TO IMPROVE CONVENIENCE Evening/weekend clinics Drop-in clinics Ensuring parents can receive appointments promptly Mobile clinics Tracking and targeting transient families (Compton 2015; Bell et al. 2015)

41 Thank you! Question? Contact me at: