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Katelyn Strasser
MPH 515
April 2014
DONT HESITATE TO VACCINATE 2
History of Vaccines
It is difficult to believe that the 1796 inoculation of a young child with cowpox
would change the face of preventative medicine and lead to one of public healths
greatest achievements. Edward Jenner is famous for performing the first inoculation of
Although not popular at first, people began to see the protective health benefits of
vaccines. By the 1940s, the United States started recommending vaccinations for
children, and in 1967 the World Health Organization was successful in completely
eradicating smallpox. Although there are hopes to eliminate other diseases such as
measles, mumps, and polio, smallpox is the only disease to be eradicated globally (The
Currently, the Centers for Disease Control and Prevention, the American
before the age of two is the best way to protect them from diseases like whooping cough,
hepatitis, and measles. Vaccines are one of the most successful and cost-effective public
health interventions for preventing disease. Not only does vaccination protect the
individual from disease, but it also plays a role in protecting the entire community from a
among children 19-35 months varied by state and rates were different for various
vaccines. For example, coverage for greater than or equal to four doses of the TDaP
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vaccine was 82.5%, while coverage for MMR was at 90.8%. The general trend was that
children were more likely to be fully covered if the vaccine series had a fewer number of
shots. This was especially true in minority populations. Coverage rates by state for the
combined vaccine series showed Alaska at just 59.5%, while Hawaii boasted 80.2%.
Healthy People 2020 includes provisions of desired vaccination rates. In 2012, fifteen
states had point estimates of MMR coverage below the target of 90% (CDC, 2013).
Recent outbreaks of diseases have reinforced the need for high vaccination rates.
One example is the 2012 increase in whooping cough cases in the United States. Over
48,000 cases of pertussis were reported, and 20 deaths occurred. Most of the deaths were
in children less than three months of age. Also in 2012 were four different measles
outbreaks, instigating 55 different cases of the disease. Measles is most often brought
into the country by unvaccinated U.S. citizens returning from a foreign country, or by
foreign travelers. Currently, a large outbreak of mumps in Ohio is still spreading, and is
under surveillance. All of these examples show the seriousness of parents opting out of
vaccines. Vaccines protect the individual that is vaccinated, and also those around them
who are too young to be vaccinated (CDC Protect your baby, 2014).
Change Target
traditionally been linked to children not being vaccinated, there is an even more
disturbing trend emerging. Parental hesitancy towards vaccination is now being seen in
children with parents from a higher-level socioeconomic status. Many children whose
parents refuse all vaccines have mothers who are a college graduate and live in a
suburban household with a higher annual family income. In fact, one study concluded
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that, children whose parents delayed or refused vaccines were significantly more likely
to live in a household with an annual income of >400% of the federal poverty level; to
have a mother who was married; > 30 years of age, English speaking, or a college
graduate; to be covered by private health insurance; and to live in a household with >4
children who were 18 years of age or younger (Smith, Humiston, & Hibbs, 2011).
These children were also more likely to be from non-Hispanic white race. Interestingly,
this trend is also seen in other countries. One study from Taiwan found that caregivers
who were older than thirty, employed, and living in urban areas were less likely to have
children vaccinated (Chen et al., 2011). These parents are able to delay or decline
vaccines in many states due to philosophical or religious reasons. Half of the children
cases in a 2008 measles outbreak in San Diego, California had not received vaccines due
educated, suburban parents will be the change target for this health promotion program
The health behavior theory that I will use to address this issue is the Health Belief
Model. The Health Belief Model (HBM) has a long tradition with increasing vaccination
coverage. The polio epidemics in the 1950s led public health officials to reevaluate why
parents were not vaccinating their children. Members of the U.S. Public Health Service
found that the following four domains influenced peoples decisions about vaccinations:
susceptibility, seriousness, efficacy and safety, and social pressures and convenience.
These factors laid the groundwork for the Health Belief Model (Smith et al., 2011).
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The Health Belief Model is a value-expectancy model, meaning that in order for
people to change a behavior, they must see it as a benefit that outweighs the costs
incurred in the process. Two main constructs appear in the model. One is the perceived
threat and the other is the expected net gain. Perceived threat is made up of both
perceived severity and perceived susceptibility. Cues to take action of a certain health
behavior affects the level of perceived threat, and modifying factors such as age and race
affect both the level of perceived threat and expected net benefit. These two main
constructs are then responsible for the likelihood that a person will change his health
Vaccinations are the topic of many health promotion programs. One program in
San Diego County used a multimedia campaign to educate the public about having an
annual flu shot. This program used Rothschilds conceptual framework, which is a
health behavior. Prior to the previews, moviegoers saw a series of slides that advertised
the influenza vaccination. Then they were given a survey after the movie to see if they
recalled the message in the advertisements. Recall of the ads varied by amount of time
people had been in their seats prior to the advertisements, with a greater time producing a
greater recall percentage. Recall of specifics about the ads was relatively low. Only 12%
of people remembered specific words, and just 6% remembered the campaign slogan.
Authors of this program suggested that follow up to see if these ads produced actual
behavior change would be beneficial. Although recall rates were generally low, they still
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advise future use of movie advertisements and other public service announcements as a
income community in New York City. The Start Right Coalition is a group of 23
action research principles. Unique to this program is its work with already existing social
service and educational programs. Results of this campaign showed promising results.
From 2003-2007, the 80% rate of immunization in the target group equaled or exceeded
national rates for children ages 19 to 35-months old. The rate in 2007 then jumped up to
96.8%. Not only were rates far above the national average, but also the improvements
were maintained for five years. Investigators of the study did acknowledge that there
could have been a positive bias because they were able to carry out evaluations with more
The third health promotion program focusing on vaccination came from 2009
when there was a rapid spread of pandemic influenza A in New York. The attack rate
was high in school age children, leading the vaccination campaign to take place in the
schools. Although the program did not follow a health behavior model, there were three
different vaccination models. One used a school nurse, another used a school nurse plus
a contract nurse, and another used a team approach. Over 500,000 children were
Challenges to this program included the coordination needed to carry out a program of
this size, and the underwhelming amount of parental consent obtained (Narcisco et al.,
2012).
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The health promotion program that I would implement would be the Dont
Hesitate to Vaccinate Campaign. I think that this is appropriate for my change target
because many of these parents are delaying or refusing vaccinations. The program would
closely follow the Health Belief Model and use its two main constructs as the basis for its
specifically mothers, before delivery of the baby. The goal would be to educate parents
in settings that they would frequent during the pregnancy, including doctor offices and
parenting classes.
The first construct of perceived threat is very crucial to the success of any
program tailored after the HBM. According to DiClemente et al., Health Belief Model
programs must find a way to inspire realistic perceptions of threat among the target
both contribute to perceived threat. Parents today may not be aware of the severity of
some of these diseases because vaccines have made them much less common. Some
parents also may think that their child is unlikely to get the disease even if he or she is not
vaccinated. In one study, 90% of parents who neither delayed nor refused vaccines
thought that their child might get a disease if they werent vaccinated, while just 71% of
parents who delayed and refused vaccines thought that their child might get a disease if
To ensure that parents view refused vaccination as a real threat to their child, I
would use education and fear appeals. Education would involve information about
symptoms and side effects of the diseases that vaccines cover. Parents should also know
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about the concept of herd immunity and immunization rates in other countries. They
might perceive their child as being safe because everyone around them is vaccinated, but
statistics could show them just how many children are being exempt from vaccines and
how people from other countries may not be vaccinated. Fear appeals are messages that
show people a worst-case scenario of what could happen if they do or do not do what the
message says. They are intended to scare people into a certain health behavior. Because
people certainly become emotional over the health of their children, fear appeals may be
an effective way to persuade people. Images of sick children or real-life cases such as the
measles outbreak in San Diego mentioned earlier might change the level of perceived
The second major construct of expected net gain includes both increased
perceived value of benefits and decreased perceived barriers. Another reason why
parents may delay or refuse vaccinations is because they dont see the benefits, and dont
believe that vaccines are successful in preventing diseases (Smith et al., 2011).
Education for these parents again becomes crucial. It is important to stress the success of
vaccines in the past, and that this success may have kept them from even recognizing
some of the illnesses that children are vaccinated for today (CDC Sample key messages,
2014). Perceived barriers to vaccination could be the parents own ideas about the
vaccine. Parents might think that vaccines are unsafe or produce unwanted side effects
(Smith et al., 2011). Parents should be reminded that the United States currently has the
safest vaccine supply in its history, and that the risk of side effects are very small (CDC
Sample key messages, 2014). Myths about autism or other diseases related to vaccines
One final factor that is very important to this change target is their relationship
and advice from a trusted health professional. Parents who delay or refuse vaccinations
are significantly less likely to report having a good relationship with their health care
provider than those who do not delay or refuse vaccines (88.5% vs. 94.2%, p<0.05)
(Smith et al., 2011). The CDC also states that health professionals remain parents most
trusted source of information about vaccines for their children (CDC Sample key
messages, 2014). For this reason, educating women at pre-natal appointments could be
very valuable. Depending on the setting, this could be done through public health nurses,
the clinic or hospital nurse, mid-level providers like a nurse practitioner, physicians
Carrying out this program successfully would only be possible by using most or
all of the elements just described. Depending on the location of the program, it could be
implemented by public health professionals who work with city or state health
departments, or medical professionals such as public health nurses could also have a role.
These educators would go to existing services or educational programs like the successful
New York City vaccination program mentioned in the second health promotion program
example. Existing opportunities would occur in pre-natal classes and pre-natal visits at a
clinic or hospital. Mothers in this socioeconomic group might also be found at special
pregnancy workout classes at local gyms. I think it is important for contact with the
mother or parents to occur before the child is born, when they have more time to think
about the information. Also, parents should have made a decision by birth because the
hepatitis B vaccines first dose is at birth. The program would have the educators visit
these sites. They could have a small presentation set up with power points or other media
DONT HESITATE TO VACCINATE 10
tools. Additionally, pamphlets and other information from sources like the CDC should
be given out. It would be a wise decision to follow-up with these parents right before the
baby is due. Part of the HBM is using cues to action. The cue to action here could be a
References
Centers for Disease Control and Prevention. (2013). National, state, and local area
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6236a1.htm?s_cid=m
m6236a1_e
Centers for Disease Control and Prevention. (2014). Protect your baby with
Centers for Disease Control and Prevention. (2014). Sample key messages. Retrieved
from http://www.cdc.gov/vaccines/events/niiw/
Chen, M., Wang, R., Schneider, J., Tsai, C., Jiang, D., Hung, M., & Lin, L. (2011). Using
doi:10.1080/07370016.2011.539087
DiClemente, R. J., Salazar, L. F., & Crosby, R. A. (2013). Health Behavior Theory for
Findley, S.E., Sanchez, M., Meija, M., Ferreira, R., Pena, O., Matos, S., Stockwell, M., &
10.1177/15424839909331544
Narciso, H., Pathela, P., Morgenthau, B., Kansagra, S., May, L., Scaccia, A., & Zucker, J.
Peddecord, K., Jacobson, I., Engelberg, M., Kwizera, L., Macias, V., & Gustafson, K.
596-613.
Smith, P.J., Humiston, S.G., Hibbs, B. (2011). Parental delay or refusal of vaccine
doses, childhood vaccination coverage at 24 months of age, and the Health Belief
from http://www.historyofvaccines.org/content/timelines/all.