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Increasing Immunization Adherence Among Infants of Low-income Parents: The Effects of Visually Enhanced Education
ORIGINAL RESEARCH
Increasing Immunization Adherence Among Infants of Low-income Parents: The Effects of Visually Enhanced Education Michelle M. Papachrisanthou, DNP, APRN, CPNP-PC, Rebecca A. Lorenz, PhD, RN, and Deborah G. Loman, PhD, APRN, CPNP-PC ABSTRACT
Many children do not receive their recommended immunizations in a timely manner. In this study we compare a visually enhanced educational (VEE) intervention to usual care (UC) among infants of lowincome parents. Parents in the intervention group (n ¼ 40) received VEE, whereas control group participants (n ¼ 40) received UC. Adherence (yes/no) to the recommended immunization schedule measured and the VEE group was significantly more adherent to the recommended immunization schedule at 2 (P ¼ .014), 4 (P ¼ .041), and 6 (P ¼ .042) months compared with the control group. Using VEE may increase adherence to the recommended immunization schedule. Keywords: adherence, education, immunizations, pictures Ó 2016 Elsevier, Inc. All rights reserved.
I
mmunizations are the most effective measure available to keep children free from communicable disease.1 However, not all children are immunized or immunized on-time. This leaves many children at risk for disease and, possibly, death. Over the last 2 decades, pertussis and measles outbreaks have afflicted thousands of young children. In 2012, there were 48,277 pertussis cases; 4,994 cases were in infants < 1 year of age and 16 deaths were reported in children 11 months of age.2 Although there was a decrease in the number of reported pertussis cases in 2014 (28,660), there were still 8 deaths in infants 11 months old.3 In fact, 200 children die each year from vaccine-preventable diseases in the United States.4 Because vaccine-preventable diseases continue to affect the US, innovative solutions must be pursued to increase parental adherence to the recommended age-specific immunization schedule. The Advisory Committee on Immunization Practice (ACIP) provides practitioners with age-specific immunization schedule recommendations, which are endorsed by the American Academy of Pediatrics (AAP) and the
www.npjournal.org
American Academy of Family Physicians (AAFP).5 The recommendations indicate the number of immunizations needed, specific ages to administer, and proper spacing intervals.5 Healthy People 2020 goals aim for 90% immunization adherence by age 2 years. Yet, national immunization survey data for 2014 revealed that only 72% of children in the US were adherent to the recommended immunization schedule by 35 months of age, with even lower rates in children from lowincome families (67%).6 These figures emphasize the need for further efforts to increase immunization rates. The catalyst for the current study was the substandard immunization adherence rate (58%) at 35 months of age within the study’s intervention facility. PICTURES AND MULTIMEDIA EFFECTIVENESS
Several studies have documented the effectiveness of using pictures and multimedia as a means to heighten patients’ knowledge, increase attention, improve satisfaction, and deepen recall of information.7-11 Bodurka and Schlumbrecht7 recruited parents to watch an 8-minute educational video on the human The Journal for Nurse Practitioners - JNP
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papillomavirus vaccine. At baseline, 57% of parents were supportive of the human papillomavirus immunization for their child.7 This rose significantly to 94% after watching the video.7 Horne et al.12 used 3 components in the intervention group that focused on risk of disease: a mother’s written perspective about her child with measles; pictures of children with measles, mumps, and rubella disease; and 3 warnings on the importance of immunization. Findings revealed a significant positive change in adult immunization attitudes from baseline to posttest in the intervention group, but not in the comparison groups.12 The use of pictures and multimedia has demonstrated positive effects on patient outcomes and health communication. However, no research is available on the use of pictures of children with vaccine-preventable diseases to increase age-specific immunization adherence. The purpose of this study was to compare on-time immunization adherence at 2, 4, and 6 months between a group of infants whose parents received visually enhanced education (VEE) and a group whose parents received usual care (UC; ie, verbal education alone). THEORETICAL FRAMEWORK
The theory of multimedia learning posits that learning occurs when people build mental images through words and pictures.13 We postulated that showing parents pictures of children with vaccinepreventable diseases along with a brief discussion about the consequences of each disease may motivate parents to get their child immunized on-time. In this study, multimedia learning theory was applied through the use of pictures that corresponded to the most serious vaccine-preventable diseases immunized against during the study period. The 5 pictures of children who had pertussis, hepatitis B, meningitis, polio, and tetanus were obtained from the Immunization Action Coalition website.14 METHODS Study Design
A 2-group quasi-experimental design was used. Institutional review board approval was received from the university and letters of agreement were obtained from both federally qualified health centers. Two data collection sites were used to reduce 2
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contamination between the VEE and UC groups. Both sites were well-established, federally qualified health centers in low-income areas serving mainly inner-city Medicaid patients from birth to 21 years of age. Both sites were located in the same midwestern state approximately 10 miles apart and part of a larger nonprofit organization with similar clinic routines, office reminder methods, and immunization schedules. Data were collected in both groups from November 2011 through October 2012. The immunizations tracked in this study included 3 doses of diphtheria, tetanus, and acellular pertussis (DTaP), inactivated polio, Hemophilus influenzae B, prevnar, and 2 doses of hepatitis B. Adherence (yes/no) to the recommended immunization schedule was defined as doses received when the infants were approximately 2 months (42-93 days), 4 months (94-156 days), and 6 months (157-218 days) of age. These age ranges followed guidelines approved by the ACIP, AAP, and AAFP to allow for parent-provider flexibility in scheduling.15 A sample size of 34 from the VEE site and 34 from the UC site achieved a power of 80% to detect a 20% difference in the proportion of patients with delayed immunizations. This sample size estimation was based on a 1-sided z-test with pooled variance with a targeted alpha level of 0.05 using PASS software (Version 2005).16 Forty parents and infants were recruited at each site to accommodate dropout. Sample
At the VEE site, parents of infants 4-14 days old were recruited for this study. This age was selected based on newborn first office visit recommendations by the AAP.15 Eligibility included the parent’s ability to speak and read English, and having an infant 4-14 days old at the first office visit. A flyer was displayed in the waiting room and eligible parents were asked if they were interested in more information about the study. Written informed consent by the parent was obtained by the principal investigator during the office visit in an examination room to protect privacy. No incentives were offered. Participants in the UC group were identified through the institution’s electronic health record system by the information technology staff. Because no personal identifiers or personal contact was made Volume
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with the UC group, a waiver of consent was obtained from the institutional review board. The charts of the first 40 infants who were 4-14 days old at the first office visit and met the criteria were reviewed and data with no identifiers extracted retrospectively. The UC group received the usual verbal education regarding immunizations and preventable diseases, expected immunization side effects, and vaccine information sheets from the registered nurse before the administration of immunizations at the 2-, 4-, and 6-month office visits. Intervention
VEE consisted of parents viewing 5 pictures of children with visible physical changes from vaccinepreventable diseases combined with verbal education. While parents were viewing the pictures, symptoms associated with the diseases, long-term disease effects, potential side-effects of the vaccines, and vaccine information sheets were discussed and questions answered by the PI. This lasted approximately 5-15 minutes. The parents viewed these pictures during the child’s initial office visit (4-14 days old) and again during the 1-month office visit (21-41 days old) before being seen by the provider. Data Analysis
Descriptive statistics were performed and groups were compared. Fisher’s exact test was used to analyze immunization adherence (yes/no) within the VEE and the UC groups. An independent-sample t-test was used to analyze differences in the number of immunization related office visits between groups. Statistical tests were 2-sided for the demographic variables and 1-sided for immunization adherence. Data were entered into SPSS software (Version 20.0) for analysis.17 RESULTS Parent and Infant Characteristics
The demographic characteristics of the 80 parents and infants were reviewed (Table 1). The mean age of the parents was 23 years (SD ¼ 5.25); 75 (94%) were female, 55 (69%) were African-American, and 71 (89%) were single. The VEE group differed significantly from the UC group on race (P ¼ .024) and marital status (P ¼ .029). www.npjournal.org
The mean age for the first visit was 6.6 days (SD ¼ 2.0); 49 (61%) were male, 51 (64%) were African-American, and 77 (97%) had Medicaid insurance. A statistical difference was noted between groups regarding race (P ¼ .007). Immunization Adherence
Infant immunization records for 2, 4, and 6 months of age were reviewed. None of the parents in the intervention group dropped out of the study. Fisher’s exact test showed a statistically significant age-specific immunization adherence in the VEE group compared with the UC group at the 2-month visit [c2(1) ¼ 7.314, P ¼ .014], 4-month visit [c2(1) ¼ 5.230, P ¼ .041], and 6-month visit [c2(1) ¼ 5.051, P ¼ .042] (see Table 2). By 7 months of age (218 days old), 68% of those in the VEE group compared with 33% of the UC group were fully immunized for all 3 sets of immunizations. The data were then examined for differences in immunization adherence related to parent race and marital status using Yates’s chi-square analyses.18 There were no significant differences by race for immunization adherence at 2 [c2(3) ¼ 0.34, P ¼ .952], 4 [c2(3) ¼ 0.966, P ¼ .810], or 6 [c2(3) ¼ 2.359, P ¼ .501] months. Similarly, there were no significant differences by marital status for adherence at 2 [c2(1) ¼ 0.161, P ¼ .688], 4 [c2(1) ¼ 0.012, P ¼ .913], or 6 [c2(1) ¼ 0.102, P ¼ .749] months. Immunization Visits
An independent-sample t-test was used to analyze the difference between the mean numbers of immunization visits between groups. The VEE group had a mean of 2.5 visits and the UC group had a mean of 2.0 visits, which was statistically different [t(78) ¼ 2.582, P ¼ .011]. DISCUSSION
To our knowledge, this study is the first to examine use of pictures of vaccine-preventable diseases to improve on-time immunization rates. Findings indicate that the VEE group adhered to the recommended age-specific immunization schedule compared with the UC group. Greater adherence in the VEE group may reflect an effort by parents to protect their child from the potential of illness The Journal for Nurse Practitioners - JNP
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Table 1. Baseline Parent and Infant Characteristics
Parent Characteristics Age, in years [mean (SD)]
Parent Intervention (n ¼ 40) 24 (5.6)
Parent Control (n ¼ 40) 22.9 (4.9)
Relationship Mom
37 (92.5%) 2 (5%)
1 (2.5%)
Guardian
1 (2.5%)
1 (2.5%)
Age, in days [mean (SD)]
.513
Gender
.024a
Race Caucasian
13 (32.5%)
African-American
22 (55%) 5 (12.5%)
4 (10%) 33 (82.5%) 3 (7.5%)
Insurance Medicaid
.343
38 (95%)
Dad
Hispanic
P-value
.222 38 (95%)
Infant Characteristics
39 (97.5%)
Infant Intervention (n ¼ 40) 6.4 (2.0)
Infant Control (n ¼ 40) 6.7 (2.0)
26 (65%)
23 (57.6%)
Female
14 (35%)
17 (42.4%)
.007a
Race Caucasian
12 (30%)
African-American
21 (52.5%)
1 (2.5%) 30 (70%)
Hispanic
4 (10%)
3 (7.5%)
Biracial
2 (5%)
6 (15%)
Other
1 (2.5%)
0 (0%)
Insurance
.222 38 (95%)
39 (97.5%)
Private
2 (5%)
0 (0%)
Private
2 (5%)
0 (0%)
Self-pay
0 (0%)
1 (2.5%)
Self-pay
0 (0%)
1 (2.5%)
Employment Employed Not employed
.225 9 (22.5%)
4 (10%)
31 (77.5%)
36 (90%)
Single
Vaccine for children
.494
Yes
38 (95%)
40 (100%)
No
2 (5%)
0 (0%)
a
Marital status Married
.476 .491
Male
Medicaid
P-value
.029 8 (20%)
1 (2.5%)
32 (80%)
39 (97.5%)
Phone
1.00
Yes
39 (97.5%)
39 (97.5%)
No
1 (2.5%)
1 (2.5%)
Transportation
.348
Yes
36 (90%)
32 (80%)
No
4 (10%)
8 (20%)
Other children
.823
Yes
20 (50%)
22 (55%)
No
20 (50%)
14 (45%)
The t-test was used for age; Pearson’s c2 was used for relationship to child, race, and insurance; c2 was used for age and gender; Fisher’s exact test was used for employment, marital status, phone, transportation, other children, and vaccine for children. a
P < .05.
associated with not immunizing. Horne et al.12 found that educating about disease risks from failure to immunize had positive effects on parental immunization attitudes. This type of approach may 4
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be more effective than focusing on myths surrounding immunizations.12 Further, Smith19 indicated that immunization risk communication should involve educating parents that refusing Volume
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Table 2. On-time Adherence Between Groups On-time (yes)
On-time (no)
Intervention
39 (97.5%)
1 (2.5%)
Control
31 (77.5%)
9 (22.5%)
Total
70 (87.5%)
10 (12.5%)
P-value
2 months
.014a
4 months Intervention
34 (85%)
6 (15%)
Control
25 (62.5%)
15 (37.5%)
Total
59 (73.8%)
21 (26.3%)
Intervention
27 (67.5%)
13 (32.5%)
Control
17 (42.5%)
23 (57.5%)
Total
44 (55%)
36 (45%)
.041a
6 months
.042a
Fisher’s exact test was used for immunization on-time adherence. a P < .05.
immunizations presents the greatest risk for their child. Timely immunizations are of upmost importance to the health of children and herd immunity. As many as 1 in 4 children do not receive their immunizations on-time.15 The effects of timely immunizations were documented by Glanz and colleagues,20 who found that children who were undervaccinated by 3 or 4 doses of DTaP were 19 and 28 times more likely to contract pertussis than children who received the recommended agespecific DTaP immunizations. Ingenious approaches, such as the use of VEE, and text messages, suggested by Ahlers-Schmidt et al.,21 are proactive designs to promote on-time adherence in immunization. Delaying immunization appointments not only has been linked to an increase in vaccine-preventable diseases, but has also been associated with vaccine hesitancy. According to the working group for vaccine hesitancy, known as SAGE (Strategic Advisory Group of Experts), vaccine hesitancy can be impacted by reducing complacency, improving convenience, and increasing confidence.22 Vaccine hesitancy may be viewed as a continuum with the individual or parent who accepts all immunizations with no apprehension on one end, to the parent who refuses all immunizations on the other.22 Additional variables of vaccine hesitancy include, but are not restricted to, www.npjournal.org
disasters, fear of needles, and lack of worry over vaccine-preventable diseases.22 One of the most effective tools to overcome vaccine hesitancy is proper provider communication.23 Using a methodical strategy, a 2-way process based on theory that incorporates media and/or technology, may positively influence vaccine-hesitant parents.23 Parents who receive VEE may understand the possible negative effects that could harm their child while learning the benefits of timely immunization during well-child care. Parents may recall the vaccine information and visit their child’s provider as scheduled, as noted in this study. Clinicians need to enforce this concept by reviewing immunization records at every health care visit. Early identification of delayed or unimmunized children is essential and consistent with state, ACIP, and Healthy People 2020 objectives. Study findings support the use of pictures of children suffering from vaccine-preventable diseases to increase parental adherence to vaccinating their child on-time. For years this type of visual message has been used to aid in smoking and illicit drug cessation. Mannocci et al.24 found using graphic smoking pictures positively disturbed contemplating quitters, women, and smokers < 45 years of age into considering smoking cessation. Pictures of negative consequences help to generate more vivid images that may promote behavior change. Implications for Practice and Research
VEE intervention may strengthen the parentprovider relationship, allowing for open communication while minimizing confusion surrounding immunizations. This may help parents realize the priority of wellness care for their child. This is noteworthy because the UC group was less adherent and had slightly fewer immunization visits, which coincides with lack of receipt of other preventive health care.23,25 This could indicate they did not have a health care relationship established. Extending the length of VEE through the first 2 years of the child’s life and including other vaccinepreventable disease pictures may reveal an even stronger adherence to the recommended immunization schedule. The promising results indicate that our study needs to be replicated with a larger sample size, The Journal for Nurse Practitioners - JNP
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random assignments, a more diverse population, and an extended follow-up time beyond 24 months of age. Future research should examine how many intervention sessions are needed to sustain the effect. Use of VEE was reasonable for office use with minimal costs. Costs involved the printing of the pictures and the extra provider time to deliver the intervention message. Having registered nurses deliver VEE is one way to avoid increased provider time during the well-child visit. This would allow for maintained office flow and prevent increased wait times for the provider and parents. Limitations
We acknowledge some limitations to our study. Parents’ education level was not available for the control group, so the effects of education on on-time immunization adherence could not be examined. There were significant differences in race and marital status; however, after analyzing the data, there were no significant differences in adherence at the 2-, 4-, or 6-month visits for race or marital status between groups. Future studies should use a prospective, randomized design with a larger sample size to overcome these issues. Finally, because our study was limited to families seeking care at 2 federally qualified health centers located in the midwestern US, generalization should not be made beyond this population. The VEE group had more immunization visits than the UC group, which could account for the higher immunization adherence. It is unclear whether the VEE or the additional time spent educating the parents, both visually and verbally, not only increased adherence to the recommended immunization schedule but may have strengthened communication between the patient and provider, thus contributing to the positive findings in the VEE group. Some of the infants in the VEE group were seen in the clinic 3 times, as compared with the UC group infants who were seen 2 times. This is important as it supports timely immunizations and preventive care. Glanz et al.26 found that undervaccinated children had lower receipt of outpatient visits. Furthermore, a Swiss study affirmed partially vaccinated or unvaccinated children had fewer office visit contacts compared with children 6
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who were up to date on immunizations.25 Research suggests that providers who engage with parents in a nonconfrontational way and elicit on-going educational dialog have more impact on the parent whose child is undervaccinated or unvaccinated.12,26 CONCLUSION
Ensuring that a child obtains timely immunizations is critical to the child’s health and well-being and to the health of the community. The results of this study suggest that parental exposure to pictures may increase immunization adherence rates. This approach may motivate parents to engage in behavioral changes that will positively influence on-time immunization adherence. Further research using a more diverse population, larger samples, random assignment, and extended study time are needed to explore the benefits of using VEE to increase immunization adherence rates. References 1. Kennedy A, Lavail K, Nowak G, Basket M, Landry S. Confidence about vaccines in the United States: understanding parents’ perceptions. Health Aff (Project Hope). 2011;30(6):1151-1159. 2. US Centers for Disease Control and Prevention. 2012 final pertussis surveillance report. 2013. http://www.cdc.gov/pertussis/downloads/ pertuss-surv-report-2012.pdf/. Accessed November 3, 2015. 3. US Centers for Disease Control and Prevention. 2014 provisional pertussis surveillance report. 2015; http://www.cdc.gov/pertussis/downloads/ pertuss-surv-report-2014.pdf/. Accessed September 8, 2015. 4. Poland GA, Jacobson RM, Ovsyannikova IG. Trends affecting the future of vaccine development and delivery: the role of demographics, regulatory science, the anti-vaccine movement, and vaccinomics. Vaccine. 2009;27(25-26):3240-3244. 5. General recommendations on immunization—recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2011;60(2):1-64. 6. Hill HA, Elam-Evans LD, Yankey D, Singleton JA, Kolasa M. National, state, and selected local area vaccination coverage among children aged 19-35 months—United States, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(33): 889-896. 7. Bodurka DC, Schlumbrecht MP. Human papillomavirus vaccine acceptability: is multimedia education ready for prime time? Gynecol Oncol. 2010;118(2): 101-102. 8. Hoppe DJ, Denkers M, Hoppe FM, Wong IH. The use of video before arthroscopic shoulder surgery to enhance patient recall and satisfaction: a randomized-controlled study. J Shoulder Elbow Surg. 2014;23(6): e134-e139. 9. Houts PS, Doak CC, Doak LG, Loscalzo MJ. The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence. Patient Educ Couns. 2006;61(2):173-190. 10. Kakkilaya V, Groome LJ, Platt D, et al. Use of a visual aid to improve counseling at the threshold of viability. Pediatrics. 2011;128(6):e1511-e1519. 11. Wu KL, Chen SR, Ko WC, et al. The effectiveness of an accessibility-enhanced multimedia informational educational programme in reducing anxiety and increasing satisfaction of patients undergoing cardiac catheterisation. J Clin Nurs. 2014;23(13-14):2063-2073. 12. Horne Z, Powell D, Hummel JE, Holyoak KJ. Countering antivaccination attitudes. Proc Natl Acad Sci USA. 2015;112(33):10321-10324. 13. Mayer RE. The Cambridge Handbook of Multimedia Learning—Cognitive Theory of Multimedia Learning. New York: Cambridge University Press; 2005. 14. Immunization Action Coalition. IAC image library. 2011. http://www .immunize.org/photos/. Accessed July 13, 2015. 15. Luman ET, Shaw KM, Stokley SK. Compliance with vaccination recommendations for U.S. children. Am J Prev Med. 2008;34(6):463-470.
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16. Power Analysis and Sample Size Software (PASS), Version 2005 [computer program]. Kaysville, UT: NCSS Statistical Software; 2005. 17. IBM SPSS Statistics for Windows, Version 20.0 [computer program]. Armonk, NY: IBM Corporation; 2011. 18. Preacher KJ. Calculation for the chi-square test: an interactive calculation tool for chi-square tests of goodness of fit and independence [computer software]. 2001. http://quantpsy.org. Accessed November 10, 2015. 19. Smith MJ. Promoting vaccine confidence. Infect Dis Clin N Am. 2015;29(4):759-769. 20. Glanz JM, Narwaney KJ, Newcomer SR, et al. Association between undervaccination with diphtheria, tetanus toxoids, and acellular pertussis (DTaP) vaccine and risk of pertussis infection in children 3 to 36 months of age. JAMA Pediatr. 2013;167(11):1060-1064. 21. Ahlers-Schmidt CR, Chesser AK, Nguyen T, et al. Feasibility of a randomized controlled trial to evaluate text reminders for immunization compliance in kids (TRICKS). Vaccine. 2012;30(36):5305-5309. 22. MacDonald NE, the SAGE Working Group on Vaccine Hesitancy. Vaccine hesitancy: definition, scope and determinants. Vaccine. 2015;33(34): 4161-4164. 23. Goldstein S, MacDonald NE, Guirguis S, the SAGE Working Group on Vaccine Hesitancy. Health communication and vaccine hesitancy. Vaccine. 2015;33(34):4212-4214. 24. Mannocci A, Colamesta V, Conti V, et al. Demographic characteristics, nicotine dependence, and motivation to quit as possible determinants of smoking behaviors and acceptability of shocking warnings in Italy. Biomed Res Int. 2014;2014:723035.
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25. Bielicki JA, Achermann R, Berger C. In touch but not up-to-date: Ambulatory visits and vaccination status in a cohort of young Swiss children. Vaccine. 2013;31(46):5375-5380. 26. Glanz JM, Newcomer SR, Narwaney KJ, Hambidge SJ. A population-based cohort study of undervaccination in 8 managed care organizations across the United States. JAMA Pediatr. 2013;167(3):274-281.
All authors are affiliated with the Saint Louis University School of Nursing in Saint Louis, MO. Michelle M. Papachrisanthou, DNP, APRN, CPNP-PC, is an assistant professor. She can be reached at [email protected]. Rebecca A. Lorenz, PhD, RN, is an associate professor; and Deborah G. Loman, PhD, APRN, CPNP-PC, is an associate professor. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/16/$ see front matter © 2016 Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2015.12.021
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Increasing Immunization Adherence Among Infants of Low-income Parents: The Effects of Visually Enhanced Education Michelle M. Papachrisanthou, DNP, APRN, CPNP-PC, Rebecca A. Lorenz, PhD, RN, and Deborah G. Loman, PhD, APRN, CPNP-PC ABSTRACT
Many children do not receive their recommended immunizations in a timely manner. In this study we compare a visually enhanced educational (VEE) intervention to usual care (UC) among infants of lowincome parents. Parents in the intervention group (n ¼ 40) received VEE, whereas control group participants (n ¼ 40) received UC. Adherence (yes/no) to the recommended immunization schedule measured and the VEE group was significantly more adherent to the recommended immunization schedule at 2 (P ¼ .014), 4 (P ¼ .041), and 6 (P ¼ .042) months compared with the control group. Using VEE may increase adherence to the recommended immunization schedule. Keywords: adherence, education, immunizations, pictures Ó 2016 Elsevier, Inc. All rights reserved.
I
mmunizations are the most effective measure available to keep children free from communicable disease.1 However, not all children are immunized or immunized on-time. This leaves many children at risk for disease and, possibly, death. Over the last 2 decades, pertussis and measles outbreaks have afflicted thousands of young children. In 2012, there were 48,277 pertussis cases; 4,994 cases were in infants < 1 year of age and 16 deaths were reported in children 11 months of age.2 Although there was a decrease in the number of reported pertussis cases in 2014 (28,660), there were still 8 deaths in infants 11 months old.3 In fact, 200 children die each year from vaccine-preventable diseases in the United States.4 Because vaccine-preventable diseases continue to affect the US, innovative solutions must be pursued to increase parental adherence to the recommended age-specific immunization schedule. The Advisory Committee on Immunization Practice (ACIP) provides practitioners with age-specific immunization schedule recommendations, which are endorsed by the American Academy of Pediatrics (AAP) and the
www.npjournal.org
American Academy of Family Physicians (AAFP).5 The recommendations indicate the number of immunizations needed, specific ages to administer, and proper spacing intervals.5 Healthy People 2020 goals aim for 90% immunization adherence by age 2 years. Yet, national immunization survey data for 2014 revealed that only 72% of children in the US were adherent to the recommended immunization schedule by 35 months of age, with even lower rates in children from lowincome families (67%).6 These figures emphasize the need for further efforts to increase immunization rates. The catalyst for the current study was the substandard immunization adherence rate (58%) at 35 months of age within the study’s intervention facility. PICTURES AND MULTIMEDIA EFFECTIVENESS
Several studies have documented the effectiveness of using pictures and multimedia as a means to heighten patients’ knowledge, increase attention, improve satisfaction, and deepen recall of information.7-11 Bodurka and Schlumbrecht7 recruited parents to watch an 8-minute educational video on the human The Journal for Nurse Practitioners - JNP
1
papillomavirus vaccine. At baseline, 57% of parents were supportive of the human papillomavirus immunization for their child.7 This rose significantly to 94% after watching the video.7 Horne et al.12 used 3 components in the intervention group that focused on risk of disease: a mother’s written perspective about her child with measles; pictures of children with measles, mumps, and rubella disease; and 3 warnings on the importance of immunization. Findings revealed a significant positive change in adult immunization attitudes from baseline to posttest in the intervention group, but not in the comparison groups.12 The use of pictures and multimedia has demonstrated positive effects on patient outcomes and health communication. However, no research is available on the use of pictures of children with vaccine-preventable diseases to increase age-specific immunization adherence. The purpose of this study was to compare on-time immunization adherence at 2, 4, and 6 months between a group of infants whose parents received visually enhanced education (VEE) and a group whose parents received usual care (UC; ie, verbal education alone). THEORETICAL FRAMEWORK
The theory of multimedia learning posits that learning occurs when people build mental images through words and pictures.13 We postulated that showing parents pictures of children with vaccinepreventable diseases along with a brief discussion about the consequences of each disease may motivate parents to get their child immunized on-time. In this study, multimedia learning theory was applied through the use of pictures that corresponded to the most serious vaccine-preventable diseases immunized against during the study period. The 5 pictures of children who had pertussis, hepatitis B, meningitis, polio, and tetanus were obtained from the Immunization Action Coalition website.14 METHODS Study Design
A 2-group quasi-experimental design was used. Institutional review board approval was received from the university and letters of agreement were obtained from both federally qualified health centers. Two data collection sites were used to reduce 2
The Journal for Nurse Practitioners - JNP
contamination between the VEE and UC groups. Both sites were well-established, federally qualified health centers in low-income areas serving mainly inner-city Medicaid patients from birth to 21 years of age. Both sites were located in the same midwestern state approximately 10 miles apart and part of a larger nonprofit organization with similar clinic routines, office reminder methods, and immunization schedules. Data were collected in both groups from November 2011 through October 2012. The immunizations tracked in this study included 3 doses of diphtheria, tetanus, and acellular pertussis (DTaP), inactivated polio, Hemophilus influenzae B, prevnar, and 2 doses of hepatitis B. Adherence (yes/no) to the recommended immunization schedule was defined as doses received when the infants were approximately 2 months (42-93 days), 4 months (94-156 days), and 6 months (157-218 days) of age. These age ranges followed guidelines approved by the ACIP, AAP, and AAFP to allow for parent-provider flexibility in scheduling.15 A sample size of 34 from the VEE site and 34 from the UC site achieved a power of 80% to detect a 20% difference in the proportion of patients with delayed immunizations. This sample size estimation was based on a 1-sided z-test with pooled variance with a targeted alpha level of 0.05 using PASS software (Version 2005).16 Forty parents and infants were recruited at each site to accommodate dropout. Sample
At the VEE site, parents of infants 4-14 days old were recruited for this study. This age was selected based on newborn first office visit recommendations by the AAP.15 Eligibility included the parent’s ability to speak and read English, and having an infant 4-14 days old at the first office visit. A flyer was displayed in the waiting room and eligible parents were asked if they were interested in more information about the study. Written informed consent by the parent was obtained by the principal investigator during the office visit in an examination room to protect privacy. No incentives were offered. Participants in the UC group were identified through the institution’s electronic health record system by the information technology staff. Because no personal identifiers or personal contact was made Volume
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with the UC group, a waiver of consent was obtained from the institutional review board. The charts of the first 40 infants who were 4-14 days old at the first office visit and met the criteria were reviewed and data with no identifiers extracted retrospectively. The UC group received the usual verbal education regarding immunizations and preventable diseases, expected immunization side effects, and vaccine information sheets from the registered nurse before the administration of immunizations at the 2-, 4-, and 6-month office visits. Intervention
VEE consisted of parents viewing 5 pictures of children with visible physical changes from vaccinepreventable diseases combined with verbal education. While parents were viewing the pictures, symptoms associated with the diseases, long-term disease effects, potential side-effects of the vaccines, and vaccine information sheets were discussed and questions answered by the PI. This lasted approximately 5-15 minutes. The parents viewed these pictures during the child’s initial office visit (4-14 days old) and again during the 1-month office visit (21-41 days old) before being seen by the provider. Data Analysis
Descriptive statistics were performed and groups were compared. Fisher’s exact test was used to analyze immunization adherence (yes/no) within the VEE and the UC groups. An independent-sample t-test was used to analyze differences in the number of immunization related office visits between groups. Statistical tests were 2-sided for the demographic variables and 1-sided for immunization adherence. Data were entered into SPSS software (Version 20.0) for analysis.17 RESULTS Parent and Infant Characteristics
The demographic characteristics of the 80 parents and infants were reviewed (Table 1). The mean age of the parents was 23 years (SD ¼ 5.25); 75 (94%) were female, 55 (69%) were African-American, and 71 (89%) were single. The VEE group differed significantly from the UC group on race (P ¼ .024) and marital status (P ¼ .029). www.npjournal.org
The mean age for the first visit was 6.6 days (SD ¼ 2.0); 49 (61%) were male, 51 (64%) were African-American, and 77 (97%) had Medicaid insurance. A statistical difference was noted between groups regarding race (P ¼ .007). Immunization Adherence
Infant immunization records for 2, 4, and 6 months of age were reviewed. None of the parents in the intervention group dropped out of the study. Fisher’s exact test showed a statistically significant age-specific immunization adherence in the VEE group compared with the UC group at the 2-month visit [c2(1) ¼ 7.314, P ¼ .014], 4-month visit [c2(1) ¼ 5.230, P ¼ .041], and 6-month visit [c2(1) ¼ 5.051, P ¼ .042] (see Table 2). By 7 months of age (218 days old), 68% of those in the VEE group compared with 33% of the UC group were fully immunized for all 3 sets of immunizations. The data were then examined for differences in immunization adherence related to parent race and marital status using Yates’s chi-square analyses.18 There were no significant differences by race for immunization adherence at 2 [c2(3) ¼ 0.34, P ¼ .952], 4 [c2(3) ¼ 0.966, P ¼ .810], or 6 [c2(3) ¼ 2.359, P ¼ .501] months. Similarly, there were no significant differences by marital status for adherence at 2 [c2(1) ¼ 0.161, P ¼ .688], 4 [c2(1) ¼ 0.012, P ¼ .913], or 6 [c2(1) ¼ 0.102, P ¼ .749] months. Immunization Visits
An independent-sample t-test was used to analyze the difference between the mean numbers of immunization visits between groups. The VEE group had a mean of 2.5 visits and the UC group had a mean of 2.0 visits, which was statistically different [t(78) ¼ 2.582, P ¼ .011]. DISCUSSION
To our knowledge, this study is the first to examine use of pictures of vaccine-preventable diseases to improve on-time immunization rates. Findings indicate that the VEE group adhered to the recommended age-specific immunization schedule compared with the UC group. Greater adherence in the VEE group may reflect an effort by parents to protect their child from the potential of illness The Journal for Nurse Practitioners - JNP
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Table 1. Baseline Parent and Infant Characteristics
Parent Characteristics Age, in years [mean (SD)]
Parent Intervention (n ¼ 40) 24 (5.6)
Parent Control (n ¼ 40) 22.9 (4.9)
Relationship Mom
37 (92.5%) 2 (5%)
1 (2.5%)
Guardian
1 (2.5%)
1 (2.5%)
Age, in days [mean (SD)]
.513
Gender
.024a
Race Caucasian
13 (32.5%)
African-American
22 (55%) 5 (12.5%)
4 (10%) 33 (82.5%) 3 (7.5%)
Insurance Medicaid
.343
38 (95%)
Dad
Hispanic
P-value
.222 38 (95%)
Infant Characteristics
39 (97.5%)
Infant Intervention (n ¼ 40) 6.4 (2.0)
Infant Control (n ¼ 40) 6.7 (2.0)
26 (65%)
23 (57.6%)
Female
14 (35%)
17 (42.4%)
.007a
Race Caucasian
12 (30%)
African-American
21 (52.5%)
1 (2.5%) 30 (70%)
Hispanic
4 (10%)
3 (7.5%)
Biracial
2 (5%)
6 (15%)
Other
1 (2.5%)
0 (0%)
Insurance
.222 38 (95%)
39 (97.5%)
Private
2 (5%)
0 (0%)
Private
2 (5%)
0 (0%)
Self-pay
0 (0%)
1 (2.5%)
Self-pay
0 (0%)
1 (2.5%)
Employment Employed Not employed
.225 9 (22.5%)
4 (10%)
31 (77.5%)
36 (90%)
Single
Vaccine for children
.494
Yes
38 (95%)
40 (100%)
No
2 (5%)
0 (0%)
a
Marital status Married
.476 .491
Male
Medicaid
P-value
.029 8 (20%)
1 (2.5%)
32 (80%)
39 (97.5%)
Phone
1.00
Yes
39 (97.5%)
39 (97.5%)
No
1 (2.5%)
1 (2.5%)
Transportation
.348
Yes
36 (90%)
32 (80%)
No
4 (10%)
8 (20%)
Other children
.823
Yes
20 (50%)
22 (55%)
No
20 (50%)
14 (45%)
The t-test was used for age; Pearson’s c2 was used for relationship to child, race, and insurance; c2 was used for age and gender; Fisher’s exact test was used for employment, marital status, phone, transportation, other children, and vaccine for children. a
P < .05.
associated with not immunizing. Horne et al.12 found that educating about disease risks from failure to immunize had positive effects on parental immunization attitudes. This type of approach may 4
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be more effective than focusing on myths surrounding immunizations.12 Further, Smith19 indicated that immunization risk communication should involve educating parents that refusing Volume
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Table 2. On-time Adherence Between Groups On-time (yes)
On-time (no)
Intervention
39 (97.5%)
1 (2.5%)
Control
31 (77.5%)
9 (22.5%)
Total
70 (87.5%)
10 (12.5%)
P-value
2 months
.014a
4 months Intervention
34 (85%)
6 (15%)
Control
25 (62.5%)
15 (37.5%)
Total
59 (73.8%)
21 (26.3%)
Intervention
27 (67.5%)
13 (32.5%)
Control
17 (42.5%)
23 (57.5%)
Total
44 (55%)
36 (45%)
.041a
6 months
.042a
Fisher’s exact test was used for immunization on-time adherence. a P < .05.
immunizations presents the greatest risk for their child. Timely immunizations are of upmost importance to the health of children and herd immunity. As many as 1 in 4 children do not receive their immunizations on-time.15 The effects of timely immunizations were documented by Glanz and colleagues,20 who found that children who were undervaccinated by 3 or 4 doses of DTaP were 19 and 28 times more likely to contract pertussis than children who received the recommended agespecific DTaP immunizations. Ingenious approaches, such as the use of VEE, and text messages, suggested by Ahlers-Schmidt et al.,21 are proactive designs to promote on-time adherence in immunization. Delaying immunization appointments not only has been linked to an increase in vaccine-preventable diseases, but has also been associated with vaccine hesitancy. According to the working group for vaccine hesitancy, known as SAGE (Strategic Advisory Group of Experts), vaccine hesitancy can be impacted by reducing complacency, improving convenience, and increasing confidence.22 Vaccine hesitancy may be viewed as a continuum with the individual or parent who accepts all immunizations with no apprehension on one end, to the parent who refuses all immunizations on the other.22 Additional variables of vaccine hesitancy include, but are not restricted to, www.npjournal.org
disasters, fear of needles, and lack of worry over vaccine-preventable diseases.22 One of the most effective tools to overcome vaccine hesitancy is proper provider communication.23 Using a methodical strategy, a 2-way process based on theory that incorporates media and/or technology, may positively influence vaccine-hesitant parents.23 Parents who receive VEE may understand the possible negative effects that could harm their child while learning the benefits of timely immunization during well-child care. Parents may recall the vaccine information and visit their child’s provider as scheduled, as noted in this study. Clinicians need to enforce this concept by reviewing immunization records at every health care visit. Early identification of delayed or unimmunized children is essential and consistent with state, ACIP, and Healthy People 2020 objectives. Study findings support the use of pictures of children suffering from vaccine-preventable diseases to increase parental adherence to vaccinating their child on-time. For years this type of visual message has been used to aid in smoking and illicit drug cessation. Mannocci et al.24 found using graphic smoking pictures positively disturbed contemplating quitters, women, and smokers < 45 years of age into considering smoking cessation. Pictures of negative consequences help to generate more vivid images that may promote behavior change. Implications for Practice and Research
VEE intervention may strengthen the parentprovider relationship, allowing for open communication while minimizing confusion surrounding immunizations. This may help parents realize the priority of wellness care for their child. This is noteworthy because the UC group was less adherent and had slightly fewer immunization visits, which coincides with lack of receipt of other preventive health care.23,25 This could indicate they did not have a health care relationship established. Extending the length of VEE through the first 2 years of the child’s life and including other vaccinepreventable disease pictures may reveal an even stronger adherence to the recommended immunization schedule. The promising results indicate that our study needs to be replicated with a larger sample size, The Journal for Nurse Practitioners - JNP
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random assignments, a more diverse population, and an extended follow-up time beyond 24 months of age. Future research should examine how many intervention sessions are needed to sustain the effect. Use of VEE was reasonable for office use with minimal costs. Costs involved the printing of the pictures and the extra provider time to deliver the intervention message. Having registered nurses deliver VEE is one way to avoid increased provider time during the well-child visit. This would allow for maintained office flow and prevent increased wait times for the provider and parents. Limitations
We acknowledge some limitations to our study. Parents’ education level was not available for the control group, so the effects of education on on-time immunization adherence could not be examined. There were significant differences in race and marital status; however, after analyzing the data, there were no significant differences in adherence at the 2-, 4-, or 6-month visits for race or marital status between groups. Future studies should use a prospective, randomized design with a larger sample size to overcome these issues. Finally, because our study was limited to families seeking care at 2 federally qualified health centers located in the midwestern US, generalization should not be made beyond this population. The VEE group had more immunization visits than the UC group, which could account for the higher immunization adherence. It is unclear whether the VEE or the additional time spent educating the parents, both visually and verbally, not only increased adherence to the recommended immunization schedule but may have strengthened communication between the patient and provider, thus contributing to the positive findings in the VEE group. Some of the infants in the VEE group were seen in the clinic 3 times, as compared with the UC group infants who were seen 2 times. This is important as it supports timely immunizations and preventive care. Glanz et al.26 found that undervaccinated children had lower receipt of outpatient visits. Furthermore, a Swiss study affirmed partially vaccinated or unvaccinated children had fewer office visit contacts compared with children 6
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who were up to date on immunizations.25 Research suggests that providers who engage with parents in a nonconfrontational way and elicit on-going educational dialog have more impact on the parent whose child is undervaccinated or unvaccinated.12,26 CONCLUSION
Ensuring that a child obtains timely immunizations is critical to the child’s health and well-being and to the health of the community. The results of this study suggest that parental exposure to pictures may increase immunization adherence rates. This approach may motivate parents to engage in behavioral changes that will positively influence on-time immunization adherence. Further research using a more diverse population, larger samples, random assignment, and extended study time are needed to explore the benefits of using VEE to increase immunization adherence rates. References 1. Kennedy A, Lavail K, Nowak G, Basket M, Landry S. Confidence about vaccines in the United States: understanding parents’ perceptions. Health Aff (Project Hope). 2011;30(6):1151-1159. 2. US Centers for Disease Control and Prevention. 2012 final pertussis surveillance report. 2013. http://www.cdc.gov/pertussis/downloads/ pertuss-surv-report-2012.pdf/. Accessed November 3, 2015. 3. US Centers for Disease Control and Prevention. 2014 provisional pertussis surveillance report. 2015; http://www.cdc.gov/pertussis/downloads/ pertuss-surv-report-2014.pdf/. Accessed September 8, 2015. 4. Poland GA, Jacobson RM, Ovsyannikova IG. Trends affecting the future of vaccine development and delivery: the role of demographics, regulatory science, the anti-vaccine movement, and vaccinomics. Vaccine. 2009;27(25-26):3240-3244. 5. General recommendations on immunization—recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2011;60(2):1-64. 6. Hill HA, Elam-Evans LD, Yankey D, Singleton JA, Kolasa M. National, state, and selected local area vaccination coverage among children aged 19-35 months—United States, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(33): 889-896. 7. Bodurka DC, Schlumbrecht MP. Human papillomavirus vaccine acceptability: is multimedia education ready for prime time? Gynecol Oncol. 2010;118(2): 101-102. 8. Hoppe DJ, Denkers M, Hoppe FM, Wong IH. The use of video before arthroscopic shoulder surgery to enhance patient recall and satisfaction: a randomized-controlled study. J Shoulder Elbow Surg. 2014;23(6): e134-e139. 9. Houts PS, Doak CC, Doak LG, Loscalzo MJ. The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence. Patient Educ Couns. 2006;61(2):173-190. 10. Kakkilaya V, Groome LJ, Platt D, et al. Use of a visual aid to improve counseling at the threshold of viability. Pediatrics. 2011;128(6):e1511-e1519. 11. Wu KL, Chen SR, Ko WC, et al. The effectiveness of an accessibility-enhanced multimedia informational educational programme in reducing anxiety and increasing satisfaction of patients undergoing cardiac catheterisation. J Clin Nurs. 2014;23(13-14):2063-2073. 12. Horne Z, Powell D, Hummel JE, Holyoak KJ. Countering antivaccination attitudes. Proc Natl Acad Sci USA. 2015;112(33):10321-10324. 13. Mayer RE. The Cambridge Handbook of Multimedia Learning—Cognitive Theory of Multimedia Learning. New York: Cambridge University Press; 2005. 14. Immunization Action Coalition. IAC image library. 2011. http://www .immunize.org/photos/. Accessed July 13, 2015. 15. Luman ET, Shaw KM, Stokley SK. Compliance with vaccination recommendations for U.S. children. Am J Prev Med. 2008;34(6):463-470.
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16. Power Analysis and Sample Size Software (PASS), Version 2005 [computer program]. Kaysville, UT: NCSS Statistical Software; 2005. 17. IBM SPSS Statistics for Windows, Version 20.0 [computer program]. Armonk, NY: IBM Corporation; 2011. 18. Preacher KJ. Calculation for the chi-square test: an interactive calculation tool for chi-square tests of goodness of fit and independence [computer software]. 2001. http://quantpsy.org. Accessed November 10, 2015. 19. Smith MJ. Promoting vaccine confidence. Infect Dis Clin N Am. 2015;29(4):759-769. 20. Glanz JM, Narwaney KJ, Newcomer SR, et al. Association between undervaccination with diphtheria, tetanus toxoids, and acellular pertussis (DTaP) vaccine and risk of pertussis infection in children 3 to 36 months of age. JAMA Pediatr. 2013;167(11):1060-1064. 21. Ahlers-Schmidt CR, Chesser AK, Nguyen T, et al. Feasibility of a randomized controlled trial to evaluate text reminders for immunization compliance in kids (TRICKS). Vaccine. 2012;30(36):5305-5309. 22. MacDonald NE, the SAGE Working Group on Vaccine Hesitancy. Vaccine hesitancy: definition, scope and determinants. Vaccine. 2015;33(34): 4161-4164. 23. Goldstein S, MacDonald NE, Guirguis S, the SAGE Working Group on Vaccine Hesitancy. Health communication and vaccine hesitancy. Vaccine. 2015;33(34):4212-4214. 24. Mannocci A, Colamesta V, Conti V, et al. Demographic characteristics, nicotine dependence, and motivation to quit as possible determinants of smoking behaviors and acceptability of shocking warnings in Italy. Biomed Res Int. 2014;2014:723035.
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25. Bielicki JA, Achermann R, Berger C. In touch but not up-to-date: Ambulatory visits and vaccination status in a cohort of young Swiss children. Vaccine. 2013;31(46):5375-5380. 26. Glanz JM, Newcomer SR, Narwaney KJ, Hambidge SJ. A population-based cohort study of undervaccination in 8 managed care organizations across the United States. JAMA Pediatr. 2013;167(3):274-281.
All authors are affiliated with the Saint Louis University School of Nursing in Saint Louis, MO. Michelle M. Papachrisanthou, DNP, APRN, CPNP-PC, is an assistant professor. She can be reached at [email protected]. Rebecca A. Lorenz, PhD, RN, is an associate professor; and Deborah G. Loman, PhD, APRN, CPNP-PC, is an associate professor. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/16/$ see front matter © 2016 Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2015.12.021
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