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  • Factors Influencing Mothers’ Concerns about Immunization Safety: DISCUSSION

Immunization Safety disscus

In our study of African-American mothers, concern over immunization was related to a number of factors, including: lack of knowledge and control over the immunization process, lack of trust in the medical community and experiencing adverse reactions and/or hearing about purported adverse effects of vaccines. Reasons mothers had their children immunized despite concerns included social norms and/or laws supporting vaccination and fear of the consequences of not immunizing. Suggestions mothers had for reducing their concerns included improved access to information that addressed their concerns and improved provider-patient communication.

Referring to Raithatha’s concept of a risk threshold for immunization, in our study, societal norms and school/daycare immunization laws played key roles in holding participants at a subthreshold level. However, these laws may no longer keep all parents below this theoretical threshold should another factor, such as an additional vaccine safety scare (e.g., from a personal experience, heard about through the media, etc.) come into play. Additionally, normative pressure from society may be decreasing as the public becomes less supportive of immunization laws—suggested by the increase in the number of states offering philosophical exemptions. Thus, it is important to both identify and address factors underlying parental vaccine safety concerns in order to prevent parents from shifting to a position above the risk unacceptability threshold where they will cease to have their children immunized.
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Access to adequate information has been shown to affect patient outcomes in a number of preventive health choices and treatment decisions, including immunizations. Because mothers did not consider themselves informed about immunization, they may have felt a lack of control over the process. This phenomenon has been described by the Theory of Planned Behavior in which perceived control—the resources and power to perform a behavior—is an important predictor of successful completion of a behavior. Likewise, studies of patients with cancer and other chronic diseases have shown that providing information to patients keeps them engaged and gives them a sense of perceived control in the health promotion decisionmaking process. This control increases the likelihood that these patients will participate in preventive care and believe in the efficacy of therapy, reduces levels of emotional distress from treatment and encourages adherence to prescribed therapies. Patients appreciate having written information even when they believe they have little choice or a passive role in medical decision-making, such as the case of immunization. Our study confirms these findings; that is, the perception of personal control over one’s health is an important factor among African-American women.

African-American mistrust of the medical community has been described in the literature. Our finding that some focus group participants did not consider their HCPs to be their allies is consistent with other studies. Fears of experimentation led to many mothers worried about the quality of immunizations and their chemical make-up. Mistrust regarding immunization may be influenced by past abuses and racism, but this study shows that mistrust was also related to lack of information about vaccines, vaccine ingredients and quality assurance as well as poor provider-patient communication.
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This study suggests that addressing mothers’ concerns will involve improving both the information available to mothers as well as provider-patient communication (Table 6). Concerns which stemmed from experiences with relatively minor reactions to vaccines or hearing about purported reactions, such as autism, could have been reduced if mothers were better informed about these issues. In addition, further education and information available about the diseases vaccines prevent, the continued necessity of vaccines, vaccine ingredients and the vaccine process would give mothers more perceived control over the immunization process. Our study and others have indicated that providing this information in advance of the actual vaccination visit is essential for mothers to be able to digest the material and discuss it with their providers. HCPs should play a major role in disseminating this information and ensuring that mothers understand the benefits and risks for each vaccine. Studies have indicated that parents consider the health professional to be the most important source of information regarding immunization and that trust in one’s provider is associated with use of recommended preventive services. Additionally, patients are less likely to avoid treatment when they feel that their HCP will take the time to listen to their concerns. Our findings reinforce the importance of information dissemination and emphasize that good communication with a HCP can help ease apprehensions about immunization. This sentiment is echoed by Corbie-Smith et al., who suggest that an ongoing process of engagement, dialog and feedback must be established over multiple interactions with HCPs in order to counteract and prevent mistrust. Indeed, having an established relationship and good communication with a HCP have been shown to predict improved trust and delivery of preventive services.
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Table 6. Recommendations
To improve overall knowledge about vaccine risks and benefits
1) Tailored educational materials should be made available to mothers. Topics that should be included
in these materials to address concerns include:
• Adverse events following immunization; how to treat them; how to report them
• Description of the diseases that vaccines prevent; also reinforcing that these diseases exist not only in other parts of the world, but also in the United States
• Purported adverse events, such as autism
• Immunization schedule; why vaccines are given multiple times; why it’s important to immunize on time
2) HCPs should distribute and discuss these materials at a visit prior to vaccination. This could be during
prenatal care, or during an early pediatric preventive care visit.
To improve trust regarding vaccination safety
1) Educational materials should address the following topics:
• Testing and quality assurance of vaccinations
• Chemical make-up of vaccines; active and inactive ingredients
2) HCPs should attempt to build mothers’ confidence and trust in immunizations by openly addressing
their questions and concerns

Both the American College of Physicians in its position paper on racial and ethnic disparities in healthcare and the National Vaccine Advisory Committee (NVAC) in its standards for child and adolescent immunization practices indicate that clear communication between patients and providers is important to improving services. NVAC recommends that “HCPs should allow sufficient time with parents.. .to discuss the benefits of vaccines, the diseases they prevent, any known risks from vaccines, the immunization schedule and the need to receive vaccines at the recommended ages.” Also recommended is that HCPs review written material with parents and address questions and concerns. Finally, they recommend that HCPs encourage parents to inform them of any adverse events and explain to parents how to obtain medical care, if necessary.

Establishing improved provider-patient relationships to facilitate information exchange is also important because conflicting messages from the medical community may minimize the perceived importance of the vaccines. For example, vaccine shortages sent conflicting messages to mothers who, on one hand, were told the importance of timely immunization, but, on the other hand, were told that they had to delay the vaccine due to a shortage. Due to poor communication, such as lack of explanation for the shortages, mothers were confused by the situation and questioned the importance of a vaccine that had to be delayed because of insufficient supply.
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There are inherent limitations to using a qualitative method, such as focus groups, and the results may not be generalizable to a larger population. The results are used to gain insight and understanding into the nature of a problem rather than to provide statistical inference. Although we believe that the number of focus groups conducted was sufficient to reach theoretical saturation (where little new information would be provided with the addition of another group), the study was limited to three Atlanta-area counties, and participants were selected using convenience sampling. In addition, because focus groups were not stratified by income or education levels and there were no comparison groups, we were unable to ascertain if there were differences related to these demographics. Despite these limitations, we gained important insights into the specific immunization concerns of African-American mothers and the factors affecting their concerns about immunizations. From these findings, we plan on developing a number of future studies, including a national survey to validate the findings and studies to test both new tailored parental educational materials as well as the optimum timing of distribution of parental immunization materials.

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