Publications by authors named "Julie Leask"

130 Publications

School-based HPV vaccination positively impacts parents' attitudes toward adolescent vaccination.

Vaccine 2021 Jul 12;39(30):4190-4198. Epub 2021 Jun 12.

Speciality of Child and Adolescent Health, Faculty of Medicine and Health, University of Sydney, NSW, Australia.

Introduction: This qualitative study aimed to explore parental attitudes, knowledge and decision-making about HPV vaccination for adolescents in the context of a gender-neutral school-based Australian National Immunisation Program (NIP).

Methods: Semi-structured interviews with parents of adolescents eligible for HPV vaccination were undertaken as part of an evaluation of a cluster-randomised controlled trial of a complex intervention in 40 schools (2013-2015). In this qualitative study, we purposively recruited a nested sample of parents from 11 schools across two Australian jurisdictions. Interviews explored parent knowledge and understanding of the HPV vaccine program; HPV vaccination decision-making; their adolescent's knowledge about HPV vaccination; and their adolescent's understanding about HPV vaccination, sexual awareness and behaviour. Transcripts were analysed using inductive and deductive thematic analysis.

Results: Parents' of 22 adolescents had positive attitudes towards the program; the school-based delivery platform was the key driver shaping acceptance of and decision-making about HPV vaccination. They had difficulty recalling, or did not read, HPV vaccination information sent home. Some adolescents were involved in discussions about vaccination, with parents' responsible for ultimate vaccine decision-making. All parents supported in-school education for adolescents about HPV and HPV vaccination. Parents' knowledge about HPV vaccination was limited to cervical cancer and was largely absent regarding vaccination in males.

Conclusions: Parents' positive attitudes towards the NIP and inclusion of the HPV vaccine is central to their vaccine decision-making and acceptance. More intensive communication strategies including school education opportunities are required to improve parents' knowledge of HPV-related disease and to promote vaccine decision-making with adolescents.
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http://dx.doi.org/10.1016/j.vaccine.2021.05.051DOI Listing
July 2021

A systematic review and meta-analysis of effectiveness of decision aids for vaccination decision-making.

Vaccine 2021 06 26;39(28):3655-3665. Epub 2021 May 26.

National Centre for Immunisation Research and Surveillance, The Children's Hospital at Westmead, Locked Bag 4001, 2145 Westmead, NSW, Australia; University of Sydney, Susan Wakil School of Nursing and Midwifery, Camperdown, NSW 2006, Australia. Electronic address:

Background: This systematic review and meta-analysis aimed to assess the effectiveness of vaccination decision aids compared with usual care on vaccine uptake, vaccine attitudes, decisional conflict, intent to vaccinate and timeliness.

Methods: Searches were conducted in OVID Medline, OVID Embase, CINAHL, PsycINFO, the Cochrane Library and SCOPUS. Randomised controlled trials were included if they evaluated the impact of decision aids as defined by the International Patient Decision Aids Standards Collaboration. Where possible, meta-analysis was undertaken. Where meta-analysis was not possible, we conducted a narrative synthesis. Risk of bias in included trials was assessed using the Cochrane Collaboration's risk of bias tool. Data were analysed using STATA.

Results: Five RCTs were identified that evaluated the effectiveness of decision aids in the context of vaccination decision making. Meta-analysis of four studies showed that decision aids may have slightly increased vaccination uptake, but this was reduced to no effect once studies with higher risk of bias were excluded. Meta-analysis of three studies showed that decision aids moderately increased intention to vaccinate. Narrative synthesis of two studies suggested that decision aids reduced decisional conflict. One study reported that decision aids decreased perceived risk of vaccination. Content, format and delivery method of the decision aids varied across the studies. It was not clear from the information reported whether these variations affected the effectiveness of the decision aids.

Conclusion: Decision aids can assist in vaccine decision making. Future studies of decision aids could provide greater detail of the decision aids themselves, which would enable comparison of the effectiveness of different elements and formats. Standardising decision aids would also allow for easier comparison between decision aids.
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http://dx.doi.org/10.1016/j.vaccine.2021.05.021DOI Listing
June 2021

A critical review of measures of childhood vaccine confidence.

Curr Opin Immunol 2021 05 14;71:34-45. Epub 2021 May 14.

The University of Sydney, Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, Sydney, NSW, Australia.

The World Health Organization and global partners sought to identify existing measures of confidence in childhood vaccines, as part of a broader effort to measure the range of behavioural and social drivers of vaccination. We identified 14 confidence measures applicable to childhood vaccination in general, all published between 2010 and 2019. The measures examined 1-5 constructs and included a mean of 12 items. Validation studies commonly examined factor structure, internal consistency reliability, and criterion-related validity. Fewer studies examined convergent and discriminant validity, test-retest reliability, or used cognitive interviewing. Most measures were developed and validated only in high-income countries. These findings highlight the need for a childhood vaccine confidence measure validated for use in diverse global contexts.
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http://dx.doi.org/10.1016/j.coi.2021.04.002DOI Listing
May 2021

Current understandings of the impact of mandatory vaccination laws in Europe.

Expert Rev Vaccines 2021 May 30;20(5):559-575. Epub 2021 Jun 30.

Susan Wakil School of Nursing and Midwifery. Faculty of Medicine and Health, University of Sydney, Sydney, Australia.

Vaccinations are among the most successful preventive tools to protect collective health. In response to alarming vaccines preventable diseases (VPDs) outbreaks resurgence, decreased vaccination coverage and vaccine refusal, several European countries have recently revised their vaccination policies introducing or extending mandatory vaccinations. This review examines the health, political and ethical aspects of mandatory vaccination.The authors first clarify terms and definitions and propose a conceptual framework of mandatory policies. Second, they describe the current status of mandatory childhood immunization programmes in Europe, assessing selected mandatory laws. Third, as the authors conduct a systematic review of the literature (retrieving from Medline 17 relevant records between 2010 and 2020), they take an analytical approach to measure the impact of mandatory vaccination policies on both VPDs control and immunization coverage, but also on population attitudes toward vaccines. 40% of European countries currently have mandatory vaccination policies; however, policies vary widely and, although there is evidence of increased vaccine uptake, their impact on informed adherence to preventive behaviors is scant.Although mandatory vaccination policies might be needed to protect collective health in times of emergency, public health goals of VPD prevention and health promotion should primarily be pursued through health education and population empowerment.
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http://dx.doi.org/10.1080/14760584.2021.1912603DOI Listing
May 2021

Examining Australian public perceptions and behaviors towards a future COVID-19 vaccine.

BMC Infect Dis 2021 Jan 28;21(1):120. Epub 2021 Jan 28.

Office of Medical Education, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.

Background: As immunisation program launches have previously demonstrated, it is essential that careful planning occurs now to ensure the readiness of the public for a COVID-19 vaccine. As part of that process, this study aimed to understand the public perceptions regarding a future COVID-19 vaccine in Australia.

Methods: A national cross-sectional online survey of 1420 Australian adults (18 years and older) was undertaken between 18 and 24 March 2020. The statistical analysis of the data included univariate and multivariable logistic regression model analysis.

Results: Respondents generally held positive views towards vaccination. Eighty percent (n = 1143) agreed with the statement that getting myself vaccinated for COVID-19 would be a good way to protect myself against infection. Females (n = 614, 83%) were more likely to agree with the statement than males (n = 529, 78%) (aOR = 1.4 (95% CI: 1.1-1.8); P = 0.03), while 91% of those aged 70 years and above agreed compared to 76% of 18-29-year-olds (aOR = 2.3 (95% CI:1.2-4.1); P = 0.008). Agreement was also higher for those with a self-reported chronic disease (aOR = 1.4 (95% CI: 1.1-2.0); P = 0.04) and among those who held private health insurance (aOR = 1.7 (95% CI: 1.3-2.3); P < 0.001). Beyond individual perceptions, 78% stated that their decision to vaccinate would be supported by family and friends.

Conclusion: This study presents an early indication of public perceptions towards a future COVID-19 vaccine and represents a starting point for mapping vaccine perceptions. To support an effective launch of these new vaccines, governments need to use this time to understand the communities concerns and to identify the strategies that will support engagement.
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http://dx.doi.org/10.1186/s12879-021-05833-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7840792PMC
January 2021

COVID-19 Misinformation Trends in Australia: Prospective Longitudinal National Survey.

J Med Internet Res 2021 01 7;23(1):e23805. Epub 2021 Jan 7.

The University of Sydney, Sydney, Australia.

Background: Misinformation about COVID-19 is common and has been spreading rapidly across the globe through social media platforms and other information systems. Understanding what the public knows about COVID-19 and identifying beliefs based on misinformation can help shape effective public health communications to ensure efforts to reduce viral transmission are not undermined.

Objective: This study aimed to investigate the prevalence and factors associated with COVID-19 misinformation in Australia and their changes over time.

Methods: This prospective, longitudinal national survey was completed by adults (18 years and above) across April (n=4362), May (n=1882), and June (n=1369) 2020.

Results: Stronger agreement with misinformation was associated with younger age, male gender, lower education level, and language other than English spoken at home (P<.01 for all). After controlling for these variables, misinformation beliefs were significantly associated (P<.001) with lower levels of digital health literacy, perceived threat of COVID-19, confidence in government, and trust in scientific institutions. Analyses of specific government-identified misinformation revealed 3 clusters: prevention (associated with male gender and younger age), causation (associated with lower education level and greater social disadvantage), and cure (associated with younger age). Lower institutional trust and greater rejection of official government accounts were associated with stronger agreement with COVID-19 misinformation.

Conclusions: The findings of this study highlight important gaps in communication effectiveness, which must be addressed to ensure effective COVID-19 prevention.
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http://dx.doi.org/10.2196/23805DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7800906PMC
January 2021

How heuristics and cognitive biases affect vaccination decisions.

Cad Saude Publica 2020 20;36Suppl 2(Suppl 2):e00136620. Epub 2020 Nov 20.

Faculty of Medicine and Health, University of Sydney, Sydney, Australia.

Immunization, the most successful public health intervention to date, can only be effective if eligible individuals or their legal representatives have access to vaccines and subsequently comply with their use. Under-vaccination stems from multiple causes: access, affordability, awareness, acceptance and activation. In this paper, we focus on acceptance and, specifically, on factors pertaining to individual or parental compliance, specifically the psychology of judgment and decision making. We describe how heuristics and cognitive biases - a facet of thoughts and feelings - affect vaccination decision making. Additionally, we address when and how social processes play a role and how attitudes towards vaccines might reflect a more general underlying attitude or ideology. The understanding of how decision making, with regards to vaccines occurs, and the role played by heuristics and cognitive biases can help inform more appropriate public health interventions.
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http://dx.doi.org/10.1590/0102-311X00136620DOI Listing
May 2021

Risk Communication Should be Explicit About Values. A Perspective on Early Communication During COVID-19.

J Bioeth Inq 2020 Dec 9;17(4):581-589. Epub 2020 Nov 9.

Susan Wakil School of Nursing and Midwifery, University of Sydney, 88 Mallet St, Camperdown, NSW, 2050, Australia.

This article explores the consequences of failure to communicate early, as recommended in risk communication scholarship, during the first stage of the COVID-19 pandemic in Australia and the United Kingdom. We begin by observing that the principles of risk communication are regarded as basic best practices rather than as moral rules. We argue firstly, that they nonetheless encapsulate value commitments, and secondly, that these values should more explicitly underpin communication practices in a pandemic. Our focus is to explore the values associated with the principle of communicating early and often and how use of this principle can signal respect for people's self-determination whilst also conveying other values relevant to the circumstances. We suggest that doing this requires communication that explicitly acknowledges and addresses with empathy those who will be most directly impacted by any disease-control measures. We suggest further that communication in a pandemic should be more explicit about how values are expressed in response strategies and that doing so may improve the appraisal of new information as it becomes available.
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http://dx.doi.org/10.1007/s11673-020-10057-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7651808PMC
December 2020

A Web Application About Herd Immunity Using Personalized Avatars: Development Study.

J Med Internet Res 2020 10 30;22(10):e20113. Epub 2020 Oct 30.

Department of Family and Emergency Medicine, Laval University, Quebec City, QC, Canada.

Background: Herd immunity or community immunity refers to the reduced risk of infection among susceptible individuals in a population through the presence and proximity of immune individuals. Recent studies suggest that improving the understanding of community immunity may increase intentions to get vaccinated.

Objective: This study aims to design a web application about community immunity and optimize it based on users' cognitive and emotional responses.

Methods: Our multidisciplinary team developed a web application about community immunity to communicate epidemiological evidence in a personalized way. In our application, people build their own community by creating an avatar representing themselves and 8 other avatars representing people around them, for example, their family or coworkers. The application integrates these avatars in a 2-min visualization showing how different parameters (eg, vaccine coverage, and contact within communities) influence community immunity. We predefined communication goals, created prototype visualizations, and tested four iterative versions of our visualization in a university-based human-computer interaction laboratory and community-based settings (a cafeteria, two shopping malls, and a public library). Data included psychophysiological measures (eye tracking, galvanic skin response, facial emotion recognition, and electroencephalogram) to assess participants' cognitive and affective responses to the visualization and verbal feedback to assess their interpretations of the visualization's content and messaging.

Results: Among 110 participants across all four cycles, 68 (61.8%) were women and 38 (34.5%) were men (4/110, 3.6%; not reported), with a mean age of 38 (SD 17) years. More than half (65/110, 59.0%) of participants reported having a university-level education. Iterative changes across the cycles included adding the ability for users to create their own avatars, specific signals about who was represented by the different avatars, using color and movement to indicate protection or lack of protection from infectious disease, and changes to terminology to ensure clarity for people with varying educational backgrounds. Overall, we observed 3 generalizable findings. First, visualization does indeed appear to be a promising medium for conveying what community immunity is and how it works. Second, by involving multiple users in an iterative design process, it is possible to create a short and simple visualization that clearly conveys a complex topic. Finally, evaluating users' emotional responses during the design process, in addition to their cognitive responses, offers insights that help inform the final design of an intervention.

Conclusions: Visualization with personalized avatars may help people understand their individual roles in population health. Our app showed promise as a method of communicating the relationship between individual behavior and community health. The next steps will include assessing the effects of the application on risk perception, knowledge, and vaccination intentions in a randomized controlled trial. This study offers a potential road map for designing health communication materials for complex topics such as community immunity.
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http://dx.doi.org/10.2196/20113DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7665952PMC
October 2020

Barriers to influenza vaccination of children hospitalised for acute respiratory illness: A cross-sectional survey.

J Paediatr Child Health 2021 03 22;57(3):409-418. Epub 2020 Oct 22.

Susan Wakil School of Nursing and Midwifery, The University of Sydney, Sydney, New South Wales, Australia.

Aim: To identify barriers to influenza vaccination of children hospitalised for acute respiratory illness in Australia.

Methods: A total of 595 parents of children hospitalised with acute respiratory illness across five tertiary hospitals in 2019 participated in an online survey. Multivariate logistic regression identified factors most strongly associated with influenza vaccination barriers.

Results: Odds of influenza vaccination were lower with lack of health-care provider (HCP) recommendation (adjusted odds ratio (aOR) 0.18; 95% confidence interval (CI): 0.08-0.38); if parents had difficulties (aOR 0.19; 95% CI: 0.08-0.47) or were 'neutral' (aOR 0.23; 95% CI: 0.06-0.82) in remembering to make an appointment; and if parents had difficulties (aOR 0.21; 95% CI: 0.07-0.62) or were 'neutral' (aOR 0.24; 95% CI: 0.07-0.79) regarding getting an appointment for vaccination. Odds were also lower if parents did not believe (aOR 0.27; 95% CI: 0.08-0.90) or were 'neutral' (aOR 0.15; 95% CI: 0.04-0.49) regarding whether the people most important to them would have their child/ren vaccinated against influenza. Children had lower odds of vaccination if parents did not support (aOR 0.09; 95% CI: 0.01-0.82) or were ambivalent (aOR 0.09; 95% CI: 0.01-0.56) in their support for influenza vaccination. Finally, lack of history of influenza vaccination of child (aOR 0.38; 95% CI: 0.18-0.81) and respondent (aOR 0.25; 95% CI: 0.11-0.56) were associated with lack of receipt of influenza vaccine before admission for acute respiratory infection.

Conclusions: Assisting parents in remembering and accessing influenza vaccination and encouraging health-care providers to recommend vaccination may increase uptake.
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http://dx.doi.org/10.1111/jpc.15235DOI Listing
March 2021

Australia needs a vaccine injury compensation scheme: Upcoming COVID-19 vaccines make its introduction urgent.

Aust J Gen Pract 2020 09 9;49. Epub 2020 Sep 9.

PhD, FRACP, Professorial Fellow, National Centre for Immunisation Research and Surveillance (NCIRS), NSW; Professor, Faculty of Medicine and Health, The University of Sydney [email protected] Hospital Westmead, NSW.

There is a strong public health ethical justification to introduce a vaccine injury compensation scheme in Australia, and it needs to be in place before widespread use of COVID-19 vaccines.
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http://dx.doi.org/10.31128/AJGP-COVID-36DOI Listing
September 2020

Preparing the public for COVID-19 vaccines: How can general practitioners build vaccine confidence and optimise uptake for themselves and their patients?

Aust J Gen Pract 2020 10;49(10):625-629

PhD, MPH, Dip Health Sci (Nursing), Professor, Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, NSW; Visiting Professorial Fellow, National Centre for Immunisation Research and Surveillance, NSW.

Background: The availability of a COVID-19 vaccine is being heralded as the solution to control the current COVID-19 pandemic, reduce the number of infections and deaths and facilitate resumption of our previous way of life.

Objective: The aim of this article is to provide a framework for primary care of what will be needed to optimise COVID-19 vaccine confidence and uptake in Australia once the vaccine prioritisation schedule and key target groups are known.

Discussion: While a number of vaccines are currently under development, with at least seven undergoing phase III trials (28 August 2020), it is hoped that an effective COVID-19 vaccine will become available to the public in 2021. Ensuring public confidence in vaccine safety and effectiveness will be crucial to facilitate uptake. General practitioners are at the forefront of public health, and one of the most trusted sources for patients. In this article, the authors discuss the expedited vaccine development process for COVID-19 vaccines; the likely vaccine prioritisation schedule and anticipated key target groups; the behavioural and social drivers of vaccination acceptance, including the work required to facilitate this; and the implications for general practice.
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http://dx.doi.org/10.31128/AJGP-08-20-5559DOI Listing
October 2020

Limited Role of Bots in Spreading Vaccine-Critical Information Among Active Twitter Users in the United States: 2017-2019.

Am J Public Health 2020 10;110(S3):S319-S325

Adam G. Dunn and Jason Dalmazzo are with the Discipline of Biomedical Informatics and Digital Health, University of Sydney, Sydney, Australia. Didi Surian, Maryke Steffens, Amalie Dyda, and Enrico Coiera are with the Centre for Health Informatics, Macquarie University, Sydney, Australia. Dana Rezazadegan is with the Department of Computer Science and Software Engineering, Swinburne University of Technology, Melbourne, Australia. Julie Leask is with the Susan Wakil School of Nursing and Midwifery, University of Sydney, Sydney, Australia. Aditi Dey is with the National Centre for Immunisation Research and Surveillance, University of Sydney, Sydney, Australia. Kenneth D. Mandl is with the Computational Health Informatics Program, Boston Children's Hospital, Boston, MA.

To examine the role that bots play in spreading vaccine information on Twitter by measuring exposure and engagement among active users from the United States. We sampled 53 188 US Twitter users and examined who they follow and retweet across 21 million vaccine-related tweets (January 12, 2017-December 3, 2019). Our analyses compared bots to human-operated accounts and vaccine-critical tweets to other vaccine-related tweets. The median number of potential exposures to vaccine-related tweets per user was 757 (interquartile range [IQR] = 168-4435), of which 27 (IQR = 6-169) were vaccine critical, and 0 (IQR = 0-12) originated from bots. We found that 36.7% of users retweeted vaccine-related content, 4.5% retweeted vaccine-critical content, and 2.1% retweeted vaccine content from bots. Compared with other users, the 5.8% for whom vaccine-critical tweets made up most exposures more often retweeted vaccine content (62.9%; odds ratio [OR] = 2.9; 95% confidence interval [CI] = 2.7, 3.1), vaccine-critical content (35.0%; OR = 19.0; 95% CI = 17.3, 20.9), and bots (8.8%; OR = 5.4; 95% CI = 4.7, 6.3). A small proportion of vaccine-critical information that reaches active US Twitter users comes from bots.
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http://dx.doi.org/10.2105/AJPH.2020.305902DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7532316PMC
October 2020

Midwifery care of non-vaccinating families - Insights from the Byron Shire.

Women Birth 2021 Jul 10;34(4):e416-e425. Epub 2020 Sep 10.

Sydney Nursing School, The University of Sydney, Sydney, New South Wales, Australia; School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.

Problem: Midwives may feel ill-equipped to manage clinical encounters with non-vaccinating parents.

Background: Pregnancy is a peak time in the formation of parents' vaccination views and intention. Midwives are central to maternity care in Australia. While most midwives will have infrequent contact with families who intend not to vaccinate, when they do, they must feel equipped to communicate with them in a manner which fulfils their professional responsibilities, acknowledges parental autonomy and facilitates continued engagement.

Aim: To understand how midwives can most effectively communicate with non-vaccinating parents.

Methods: We conducted in-depth interviews with 32 non-vaccinating parents and six key informant health professionals, and a focus group of six midwives. Data collection occurred in the Byron Shire of New South Wales, where childhood vaccination rates are persistently lower than national averages.

Findings: This study explores four central codes. The first, 'hold on…I'm not sure about this' providing insights into moments of doubt preceding parents' decisions not to vaccinate. The second 'Pregnancy: a decision-making focal point' reinforces the importance of effective vaccination recommendations in the antenatal period. 'Manipulation and ambivalence' examines why overzealous or unclear recommendations about vaccination are unhelpful, and the fourth central code 'engage, inform and encourage' summarise recommendations from health professionals who are experienced in communicating, apparently effectively, with non-vaccinating families.

Discussion: Insights from this study are used to recommend practical strategies which may be employed by midwives and maternity units to successfully and professionally manage clinical encounters with non-vaccinating parents.

Conclusion: Midwives are well positioned to provide clear recommendations to parents regarding childhood vaccination whilst maintaining engagement and meeting the goals of woman-centred care.
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http://dx.doi.org/10.1016/j.wombi.2020.08.007DOI Listing
July 2021

A Consent Support Resource with Benefits and Harms of Vaccination Does Not Increase Hesitancy in Parents-An Acceptability Study.

Vaccines (Basel) 2020 Sep 2;8(3). Epub 2020 Sep 2.

ASK NHMRC Centre for Research Excellence, University of Sydney, Sydney 2006, Australia.

It is unclear whether information given about the benefits and risks of routine childhood vaccination during consent may cue parental vaccine hesitancy. Parents were surveyed before and after reading vaccine consent information at a public expo event in Sydney, Australia. We measured vaccine hesitancy with Parent Attitudes about Childhood Vaccine Short Scale (PACV-SS), informed decision-making with Informed Subscale of the Decisional Conflict Scale (DCS-IS), items from Stage of Decision Making, Positive Attitude Assessment, Vaccine Safety and Side Effect Concern, and Vaccine Communication Framework (VCF) tools. Overall, 416 parents showed no change in vaccine hesitancy (mean PACV-SS score pre = 1.97, post = 1.94; diff = -0.02 95% CI -0.10 to 0.15) but were more informed (mean DCS-IS score pre = 29.05, post = 7.41; diff = -21.63 95% CI -24.17 to -18.56), were more positive towards vaccination (pre = 43.8% post = 50.4%; diff = 6.5% 95% CI 3.0% to 10.0%), less concerned about vaccine safety (pre = 28.5%, post = 23.0%, diff = -5.6% 95% CI -2.3% to -8.8%) and side effects (pre = 37.0%, post = 29.0%, diff = -8.0% 95% CI -4.0% to -12.0%) with no change in stage of decision-making or intention to vaccinate. Providing information about the benefits and risks of routine childhood vaccination increases parents' informed decision-making without increasing vaccine hesitancy.
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http://dx.doi.org/10.3390/vaccines8030500DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7565597PMC
September 2020

A systematic review of studies that measure parental vaccine attitudes and beliefs in childhood vaccination.

BMC Public Health 2020 Aug 17;20(1):1253. Epub 2020 Aug 17.

Centre for Health Informatics, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia.

Background: Acceptance of vaccines is an important predictor of vaccine uptake. This has public health implications as those who are not vaccinated are at a higher risk of infection from vaccine preventable diseases. We aimed to examine how parental attitudes and beliefs towards childhood vaccination were measured in questionnaires through a systematic review of the literature.

Methods: We systematically reviewed the literature to identify primary research studies using tools to measure vaccine attitudes and beliefs, published between January 2012 and May 2018. Studies were included if they involved a quantitative survey of the attitudes and beliefs of parents about vaccinations recommended for children. We undertook a synthesis of the results with a focus on evaluating the tools used to measure hesitancy.

Results: A total of 116 studies met the inclusion criteria, 99 used a cross sectional study design, 5 used a case control study design, 4 used a pre-post study design and 8 used mixed methods study designs. Sample sizes of included studies ranged from 49 to 12,259. The most commonly used tool was the Parent Attitudes about Childhood Vaccines (PACV) Survey (n = 7). The most common theoretical framework used was the Health Belief Model (n = 25). Questions eliciting vaccination attitudes and beliefs varied widely.

Conclusions: There was heterogeneity in the types of questionnaires used in studies investigating attitudes and beliefs about vaccination in parents. Methods to measure parental attitudes and beliefs about vaccination could be improved with validated and standardised yet flexible instruments. The use of a standard set of questions should be encouraged in this area of study.
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http://dx.doi.org/10.1186/s12889-020-09327-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7433363PMC
August 2020

Parenting and the vaccine refusal process: A new explanation of the relationship between lifestyle and vaccination trajectories.

Soc Sci Med 2020 10 5;263:113259. Epub 2020 Aug 5.

Australian Centre for Health Engagement, Evidence and Values (ACHEEV), School of Health and Society, University of Wollongong, Australia.

Recent research illuminates the characteristics of non-vaccinating parents in well-defined geographic communities, however the process by which they came to reject vaccines is less clearly understood. Between September 11th, 2017 and February 20th, 2019, we recruited a nationally derived sample of Australian parents of children under 18 years who rejected some or all vaccines for semi-structured interviews. We used various strategies, including advertising on national radio, in community centres and playgrounds in low coverage areas, and snowballing. Grounded Theory methodology guided data collection and analysis. Twenty-one parents from regional and urban locations were interviewed. All spoke of wanting happy, healthy, robust children. All endorsed parenting values and approaches aligned with modern societal expectations of taking responsibility for their child's health. They varied, however, in their lifestyle and vaccination trajectories. Participants self-identified as situated along an 'alternative' to 'mainstream' lifestyle spectrum and had moved both away from and toward vaccination over time. Some had decided before birth that they never would vaccinate their children and had not changed. Others stopped vaccinating after perceived post-vaccine reactions in their children. Still others initially rejected vaccines, but eventually accepted them. The variation and dynamic nature of the vaccination trajectories described in this study suggests that vaccine refusal is not a static trait but rather the result of ever-changing experience and continual risk assessment; not all non-vaccinating parents fit the 'alternative lifestyle' stereotype. This suggests that nuanced personalised engagement with non-vaccinating parents is more appropriate than a one-size-fits-all approach.
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http://dx.doi.org/10.1016/j.socscimed.2020.113259DOI Listing
October 2020

Designing a multi-component intervention (P3-MumBubVax) to promote vaccination in antenatal care in Australia.

Health Promot J Austr 2021 Jul 24;32(3):391-398. Epub 2020 Jul 24.

Murdoch Children's Research Institute, Parkville, Australia.

Issue Addressed: Coverage of maternal influenza and pertussis vaccines remains suboptimal in Australia, and pockets of low childhood vaccine coverage persist nationwide. Maternal vaccine uptake is estimated to be between 35% and 60% for influenza vaccination and between 65% and 80% for pertussis vaccination. Australian midwives are highly trusted and ideally placed to discuss vaccines with expectant parents, but there are no evidence-based interventions to optimise these discussions and promote maternal and childhood vaccine acceptance in the Australian public antenatal setting.

Methods: We gathered qualitative data from Australian midwives, reviewed theoretical models, and adapted existing vaccine communication tools to develop the multi-component P3-MumBubVax intervention. Through 12 interviews at two Australian hospitals, we explored midwives' vaccination attitudes and values, perceived role in vaccine advocacy and delivery, and barriers and enablers to intervention implementation. Applying the theory-based P3 intervention model, we designed intervention components targeting the Practice, Provider and Parent levels. Midwives provided feedback on prototype intervention features through two focus groups.

Results: The P3-MumBubVax intervention includes practice-level prompts and identification of a vaccine champion. Provider-level components are a vaccine communication training module, learning exercise, and website with printable fact sheets. Parent-level intervention components include text message reminders to receive influenza and pertussis vaccines in pregnancy, as well as online information on vaccine safety, effectiveness and disease severity.

Conclusions: The P3-MumBubVax intervention is the first Australian antenatal intervention designed to support both maternal and childhood vaccine uptake. A pilot study is underway to inform a planned cluster randomised controlled trial. SO WHAT?: Barriers to vaccine acceptance and uptake are complex. The P3 model is a promising evidence-informed multi-component intervention strategy targeting all three levels influencing health care decision-making.
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http://dx.doi.org/10.1002/hpja.382DOI Listing
July 2021

How risk communication could have reduced controversy about school closures in Australia during the COVID-19 pandemic.

Public Health Res Pract 2020 Jun 30;30(2). Epub 2020 Jun 30.

Sydney Health Ethics, Faculty of Medicine and Health, University of Sydney, NSW, Australia.

Although there has been consistent evidence indicating that school closures have only limited efficacy in reducing community transmission of coronavirus disease 2019 (COVID-19), the question of whether children should be kept home from school has attracted extensive and often divisive public debate in Australia. In this article we analyse the factors that drove high levels of concern among parents, teachers and the public and led to both demands for school closures in late March 2020, and to many parents' reluctance to return their children to school in May 2020. We discuss how the use of well-established principles of risk communication might have reduced much of this community concern. Then we set out a range of practical suggestions for communication practices that build trust and hence diminish concerns in relation to managing schools over the long term of the COVID-19 pandemic.
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http://dx.doi.org/10.17061/phrp3022007DOI Listing
June 2020

Ten considerations for effectively managing the COVID-19 transition.

Nat Hum Behav 2020 07 24;4(7):677-687. Epub 2020 Jun 24.

Center for Empirical Research in Economics and Behavioral Sciences, Media and Communication Science, University of Erfurt, Erfurt, Germany.

Governments around the world have implemented measures to manage the transmission of coronavirus disease 2019 (COVID-19). While the majority of these measures are proving effective, they have a high social and economic cost, and response strategies are being adjusted. The World Health Organization (WHO) recommends that communities should have a voice, be informed and engaged, and participate in this transition phase. We propose ten considerations to support this principle: (1) implement a phased approach to a 'new normal'; (2) balance individual rights with the social good; (3) prioritise people at highest risk of negative consequences; (4) provide special support for healthcare workers and care staff; (5) build, strengthen and maintain trust; (6) enlist existing social norms and foster healthy new norms; (7) increase resilience and self-efficacy; (8) use clear and positive language; (9) anticipate and manage misinformation; and (10) engage with media outlets. The transition phase should also be informed by real-time data according to which governmental responses should be updated.
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http://dx.doi.org/10.1038/s41562-020-0906-xDOI Listing
July 2020

COVID-19 is rapidly changing: Examining public perceptions and behaviors in response to this evolving pandemic.

PLoS One 2020 23;15(6):e0235112. Epub 2020 Jun 23.

Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.

Background: Since the emergence of SARS-CoV-2, the virus that causes coronavirus disease (COVID-19) in late 2019, communities have been required to rapidly adopt community mitigation strategies rarely used before, or only in limited settings. This study aimed to examine the attitudes and beliefs of Australian adults towards the COVID-19 pandemic, and willingness and capacity to engage with these mitigation measures. In addition, we aimed to explore the psychosocial and demographic factors that are associated with adoption of recommended hygiene-related and avoidance-related behaviors.

Methods: A national cross-sectional online survey of 1420 Australian adults (18 years and older) was undertaken between the 18 and 24 March 2020. The statistical analysis of the data included univariate and multivariate logistic regression analysis.

Findings: The survey of 1420 respondents found 50% (710) of respondents felt COVID-19 would 'somewhat' affect their health if infected and 19% perceived their level of risk as high or very high. 84·9% had performed ≥1 of the three recommended hygiene-related behaviors and 93·4% performed ≥1 of six avoidance-related behaviors over the last one month. Adopting avoidance behaviors was associated with trust in government/authorities (aOR: 6.0, 95% CI 2.6-11·0), higher perceived rating of effectiveness of behaviors (aOR: 4·0, 95% CI: 1·8-8·7), higher levels of perceived ability to adopt social distancing strategies (aOR: 5.0, 95% CI: 1·5-9.3), higher trust in government (aOR: 6.0, 95% CI: 2.6-11.0) and higher level of concern if self-isolated (aOR: 1.8, 95% CI: 1.1-3.0).

Interpretation: In the last two months, members of the public have been inundated with messages about hygiene and social (physical) distancing. However, our results indicate that a continued focus on supporting community understanding of the rationale for these strategies, as well as instilling community confidence in their ability to adopt or sustain the recommendations is needed.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0235112PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7310732PMC
June 2020

Feasibility and acceptability of the multi-component P3-MumBubVax antenatal intervention to promote maternal and childhood vaccination: A pilot study.

Vaccine 2020 05 19;38(24):4024-4031. Epub 2020 Apr 19.

Murdoch Children's Research Institute, 50 Flemington Road, Parkville, VIC 3052, Australia; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 50 Flemington Road, Parkville, VIC 3052, Australia; Royal Children's Hospital, 50 Flemington Road, Parkville, VIC 3052, Australia. Electronic address:

Background: Pregnancy is a critical time for vaccine decision-making, but coverage remains suboptimal for maternal influenza (45-60%) and pertussis vaccination (65-80%) in Australia. The multi-component P3-MumBubVax intervention has been designed for Australian midwives to optimise antenatal vaccine discussions and improve maternal and childhood vaccine uptake. A pilot study was conducted to assess intervention feasibility and acceptability.

Methods: P3-MumBubVax includes components at three levels: 1. Practice ('vaccine champions'; stickers to prompt and record vaccine discussions/delivery); 2. Provider (website with vaccine communication training; learning exercise; fact sheets; links to child vaccination resources); 3. Parent (SMS reminders; website; fact sheets). Midwives and pregnant women 18-22 weeks gestation were recruited at the Royal Women's Hospital, Melbourne. Post-intervention online surveys assessed intervention feasibility, implementation, acceptability and impact on vaccine uptake.

Results: Twenty-five midwives and 62 pregnant women were recruited and 19/25 midwives completed training. Surveys were returned by 18/25 midwives and 56/62 women. 14/18 midwives reported using the sticker prompts, 10/18 reported using or referring to the website, and 11/18 reported using the fact sheets. 48/56 pregnant women (86%) reported discussing influenza and 46/56 (82%) discussed pertussis vaccines with their midwives. These conversations were reported to be short (1-3 min) for 48/56 women (87%). All midwives were satisfied with the intervention and 17/18 reported feeling more confident discussing vaccines following the intervention. Women were very satisfied with SMS content (50/56; 94%) and timing (49/55; 89%), and with their vaccine discussions in general (34/56; 63%). However, 16/54 (30%) wanted more discussion about childhood vaccines. Self-reported maternal vaccine uptake was 82% (45/55) and 93% (51/55) for influenza and pertussis (baseline 2017-2018: 43% influenza, 60% pertussis) and 96% (50/52) of infants were fully vaccinated at 12 weeks.

Discussion: The P3-MumBubVax intervention is feasible and acceptable in the Australian public antenatal setting. Further evaluation is required to determine effectiveness.
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http://dx.doi.org/10.1016/j.vaccine.2020.04.010DOI Listing
May 2020

Underpinning of the sharing knowledge about immunisation (SKAI) communication approach: A qualitative study using recorded observations.

Patient Educ Couns 2020 06 26;103(6):1118-1124. Epub 2019 Dec 26.

University of Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia. Electronic address:

Objective: To refine communication strategies to assist clinician conversations with vaccine hesitant and declining parents as part of the Sharing Knowledge About Immunisation (SKAI) package.

Methods: We recorded and analysed consultations held in two Specialist Immunisation Clinics in tertiary hospitals in Australia between consenting clinicians and parents. We undertook content analysis that was both iterative and informed by the Calgary Cambridge Model of health communication and motivational interviewing.

Results: We found common strengths and opportunities in clinician's communication styles. Strengths included: rapport building; communicating care for both the parent and child; exhibiting depth of vaccination-specific communication skill and content knowledge. Opportunities for strengthening communication practices included: eliciting parents' concerns to saturation early in the consultation; structuring the consultation to prioritise and address parents' concerns; recognising and responding to parents' motivation to vaccinate; effectively closing consultations.

Conclusion: This study has synthesised clinical communication strategies from expert vaccination communicators using well-established communication frameworks to advance a unique approach to the challenging task of addressing vaccine hesitancy and refusal.

Practice Implications: The clinic observations helped us to create a structured consultation guide that can enhance and provide greater structure to a clinician's existing communication skills.
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http://dx.doi.org/10.1016/j.pec.2019.12.014DOI Listing
June 2020

Instruments that measure psychosocial factors related to vaccination: a scoping review protocol.

BMJ Open 2019 12 9;9(12):e033938. Epub 2019 Dec 9.

Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Victoria, Australia.

Introduction: As vaccine-preventable disease outbreaks increase, there is growing international interest in monitoring public attitudes towards vaccination and implementing and evaluating vaccine promotion interventions. Outcome selection and measurement are central to intervention evaluation. Measuring uptake rates alone cannot determine which elements in a multicomponent vaccine-promotion intervention are most effective, why specific populations are undervaccinated or when confidence in vaccines is wavering. To develop targeted and cost-effective interventions and policies, it is necessary to measure vaccination-related psychosocial factors such as knowledge, attitudes and aspects of decision-making. This scoping review aims to identify, compare and summarise the properties and validation of instruments for measuring vaccination-related psychosocial factors and identify gaps where no instruments exist.

Methods And Analysis: We will search Medline OVID, Embase OVID, CINAHL and PsycINFO with no date restriction, using a pilot-tested search strategy of terms related to vaccination: knowledge, attitudes, trust, acceptance and decision-making and measurement, psychometric testing or validation. This search will be supplemented with manual search and expert consultation. We will include studies that describe instrument development, adaptation or testing and include evaluation of at least two measurement properties (eg, content, criterion, or construct validity; test-retest reliability; internal consistency; sensitivity; responsiveness). Instruments measuring a vaccination-related psychosocial factor in any population will be included. All studies will be screened by one reviewer, with a sample double-screened to confirm accuracy. Disagreements will be resolved with a third reviewer. Data will be synthesised narratively and through summary tables to chart and compare instrument characteristics such as factors measured, date and/or location of development or validation, measurement properties evaluated and population.

Ethics And Dissemination: This scoping review aims to provide an overview of existing instruments and ascertain measurement gaps where no measurement instruments currently exist. The identified instruments will form the basis of an open-access online repository of instruments.
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http://dx.doi.org/10.1136/bmjopen-2019-033938DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6924734PMC
December 2019

Immunisation status screening in the emergency department: Why are we forgetting the elderly?

Australas Emerg Care 2020 Jun 24;23(2):84-89. Epub 2019 Nov 24.

The University of Sydney, Susan Wakil School of Nursing and Midwifery, Emergency Clinical Nurse Consultant, Blacktown & Mount Druitt Hospitals, Australia.

Background: Pneumonia is one of the most common reasons patients over the age of 65 years present to the Emergency Department (ED). There is a 23-valent pneumococcal vaccine (23vPPV) available under the National Immunisation Program (NIP) with demonstrated 61-71% effectiveness against Invasive Pneumococcal Disease (IPD), but only 51% of adults aged over 65 years are vaccinated in Australia.

Methods: Short semi-structured interviews were conducted with emergency nurses working across a Local Health District in Sydney New South Wales (n=9) in order to determine their knowledge, behaviour and attitudes towards immunisation status screening in the elderly who present to the ED with pneumonia. Questions were structured to the COM-B Model (capability, opportunity and motivation to change behaviour), and a thematic analysis was conducted.

Results: There were three major themes identified: (1) The importance of routinisation, (2) Low knowledge levels and, (3) The 'vaccination is for children' heuristic, as well as suggestions for future interventions to improve screening.

Conclusions: These findings clarify how to improve vaccine uptake amongst this vulnerable cohort. They suggest that emergency departments should provide education to nurses. In addition, checklists/tick boxes can prompt nurses whilst conducting routine work, which may lead to increased vaccination uptake.
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http://dx.doi.org/10.1016/j.auec.2019.10.004DOI Listing
June 2020

How organisations promoting vaccination respond to misinformation on social media: a qualitative investigation.

BMC Public Health 2019 Oct 23;19(1):1348. Epub 2019 Oct 23.

The University of Sydney, School of Public Health, Faculty of Medicine and Health, Sydney, NSW, Australia.

Background: Vaccination misinformation is associated with serious public health consequences, such as a decrease in vaccination rates and a risk of disease outbreaks. Although social media offers organisations promoting vaccination unparalleled opportunities to promote evidence and counterbalance misinformation, we know relatively little about their internal workings. The aim of this paper is to explore the strategies, perspectives and experiences of communicators working within such organisations as they promote vaccination and respond to misinformation on social media.

Methods: Using qualitative methods, we purposively sampled 21 participants responsible for routine social media activity and strategy from Australian organisations actively promoting vaccination on social media, including government health departments, local health services, advocacy groups, professional associations and technical/scientific organisations. We conducted semi-structured, in-depth interviews to explore their perspectives and practices. Applying Risk Communication principles as a lens, we used Framework Analysis to explore the data both inductively and deductively.

Results: Organisations promoting vaccination face multiple challenges on social media, including misinformation, anti-science sentiment, a complex vaccination narrative and anti-vaccine activists. They developed a range of sophisticated strategies in response, including communicating with openness in an evidence-informed way; creating safe spaces to encourage audience dialogue; fostering community partnerships; and countering misinformation with care.

Conclusions: We recommend that communicators consider directly countering misinformation because of the potential influence on their silent audience, i.e. those observing but not openly commenting, liking or sharing posts. Refutations should be straightforward, succinct and avoid emphasizing misinformation. Communicators should consider pairing scientific evidence with stories that speak to audience beliefs and values. Finally, organisations could enhance vaccine promotion and their own credibility on social media by forming strong links with organisations sharing similar values and goals.
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http://dx.doi.org/10.1186/s12889-019-7659-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6806569PMC
October 2019

Improving child immunisation rates in a disadvantaged community in New South Wales, Australia: a process evaluation for research translation.

Aust J Prim Health 2019 Oct;25(4):310-316

University of Newcastle, School of Medicine and Public Health, Callaghan, NSW 2308, Australia; and Hunter New England Health, NSW 2300, Australia.

The World Health Organization's Tailoring Immunization Programmes approach was used to develop a new strategy to increase child vaccination coverage in a disadvantaged community in New South Wales, Australia, including reminders, outreach and home visiting. After 18 months, the strategy hasn't been fully implemented. A process evaluation was conducted to identify barriers and facilitators for research translation. Participants included child health nurses, Population Health staff, managers and general practitioners. The Capability-Opportunity-Motivation model of behaviour change (COM-B) was used to develop questions. Twenty-four participants took part in three focus groups and four interviews. Five themes emerged: (i) designing and adopting new ways of working is time-consuming and requires new skills, new ways of thinking and changes in service delivery; (ii) genuine engagement and interaction across fields and institutions helps build capacity and strengthen motivation; (iii) implementation of a new strategy requires clarity; who's doing what, when and how?; (iv) it is important not to lose sight of research findings related to the needs of disadvantaged families; and (v) trust in the process and perseverance are fundamental. There was strong motivation and opportunity for change, but a need to enhance service capability. Areas requiring support and resources were identified.
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http://dx.doi.org/10.1071/PY19016DOI Listing
October 2019
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