Running head: DONT HESITATE TO VACCINATE 1

Dont hesitate to vaccinate:

A health promotion program based on the Health Belief Model

Katelyn Strasser

Concordia University Nebraska

MPH 515

April 2014
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History of Vaccines

It is difficult to believe that the 1796 inoculation of a young child with cowpox

would change the face of preventative medicine and lead to one of public healths

greatest achievements. Edward Jenner is famous for performing the first inoculation of

cowpox on an eight-year old boy in an attempt to vaccinate him against smallpox.

Although not popular at first, people began to see the protective health benefits of

vaccines. By the 1940s, the United States started recommending vaccinations for

children, and in 1967 the World Health Organization was successful in completely

eradicating smallpox. Although there are hopes to eliminate other diseases such as

measles, mumps, and polio, smallpox is the only disease to be eradicated globally (The

College of Physicians of Philadelphia, 2014).

Current Trends in Vaccination

Currently, the Centers for Disease Control and Prevention, the American

Academy of Family Physicians, and American Academy of Pediatrics support a

vaccination schedule for 14 different vaccinations. Giving babies these vaccinations

before the age of two is the best way to protect them from diseases like whooping cough,

hepatitis, and measles. Vaccines are one of the most successful and cost-effective public

health interventions for preventing disease. Not only does vaccination protect the

individual from disease, but it also plays a role in protecting the entire community from a

devastating outbreak (CDC Sample key messages, 2014).

The National Immunization Survey reported that in 2012, vaccination coverage

among children 19-35 months varied by state and rates were different for various

vaccines. For example, coverage for greater than or equal to four doses of the TDaP
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vaccine was 82.5%, while coverage for MMR was at 90.8%. The general trend was that

children were more likely to be fully covered if the vaccine series had a fewer number of

shots. This was especially true in minority populations. Coverage rates by state for the

combined vaccine series showed Alaska at just 59.5%, while Hawaii boasted 80.2%.

Healthy People 2020 includes provisions of desired vaccination rates. In 2012, fifteen

states had point estimates of MMR coverage below the target of 90% (CDC, 2013).

Recent outbreaks of diseases have reinforced the need for high vaccination rates.

One example is the 2012 increase in whooping cough cases in the United States. Over

48,000 cases of pertussis were reported, and 20 deaths occurred. Most of the deaths were

in children less than three months of age. Also in 2012 were four different measles

outbreaks, instigating 55 different cases of the disease. Measles is most often brought

into the country by unvaccinated U.S. citizens returning from a foreign country, or by

foreign travelers. Currently, a large outbreak of mumps in Ohio is still spreading, and is

under surveillance. All of these examples show the seriousness of parents opting out of

vaccines. Vaccines protect the individual that is vaccinated, and also those around them

who are too young to be vaccinated (CDC Protect your baby, 2014).

Change Target

While socioeconomic status and lack of resources to obtain vaccines has

traditionally been linked to children not being vaccinated, there is an even more

disturbing trend emerging. Parental hesitancy towards vaccination is now being seen in

children with parents from a higher-level socioeconomic status. Many children whose

parents refuse all vaccines have mothers who are a college graduate and live in a

suburban household with a higher annual family income. In fact, one study concluded
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that, children whose parents delayed or refused vaccines were significantly more likely

to live in a household with an annual income of >400% of the federal poverty level; to

have a mother who was married; > 30 years of age, English speaking, or a college

graduate; to be covered by private health insurance; and to live in a household with >4

children who were 18 years of age or younger (Smith, Humiston, & Hibbs, 2011).

These children were also more likely to be from non-Hispanic white race. Interestingly,

this trend is also seen in other countries. One study from Taiwan found that caregivers

who were older than thirty, employed, and living in urban areas were less likely to have

children vaccinated (Chen et al., 2011). These parents are able to delay or decline

vaccines in many states due to philosophical or religious reasons. Half of the children

cases in a 2008 measles outbreak in San Diego, California had not received vaccines due

to philosophical or religious reasons. Due to this disconcerting trend, the population of

educated, suburban parents will be the change target for this health promotion program

(Smith et al., 2011).

The Health Belief Model

The health behavior theory that I will use to address this issue is the Health Belief

Model. The Health Belief Model (HBM) has a long tradition with increasing vaccination

coverage. The polio epidemics in the 1950s led public health officials to reevaluate why

parents were not vaccinating their children. Members of the U.S. Public Health Service

found that the following four domains influenced peoples decisions about vaccinations:

susceptibility, seriousness, efficacy and safety, and social pressures and convenience.

These factors laid the groundwork for the Health Belief Model (Smith et al., 2011).
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The Health Belief Model is a value-expectancy model, meaning that in order for

people to change a behavior, they must see it as a benefit that outweighs the costs

incurred in the process. Two main constructs appear in the model. One is the perceived

threat and the other is the expected net gain. Perceived threat is made up of both

perceived severity and perceived susceptibility. Cues to take action of a certain health

behavior affects the level of perceived threat, and modifying factors such as age and race

affect both the level of perceived threat and expected net benefit. These two main

constructs are then responsible for the likelihood that a person will change his health

behavior (DiClemente, Salazar, & Crosby, 2013).

Examples of Vaccination Programs

Vaccinations are the topic of many health promotion programs. One program in

San Diego County used a multimedia campaign to educate the public about having an

annual flu shot. This program used Rothschilds conceptual framework, which is a

combination of educational, marketing, and legal methods used to produce a change in

health behavior. Prior to the previews, moviegoers saw a series of slides that advertised

the influenza vaccination. Then they were given a survey after the movie to see if they

recalled the message in the advertisements. Recall of the ads varied by amount of time

people had been in their seats prior to the advertisements, with a greater time producing a

greater recall percentage. Recall of specifics about the ads was relatively low. Only 12%

of people remembered specific words, and just 6% remembered the campaign slogan.

Authors of this program suggested that follow up to see if these ads produced actual

behavior change would be beneficial. Although recall rates were generally low, they still
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advise future use of movie advertisements and other public service announcements as a

way to reach diverse crowds of people (Peddecord et al., 2008).

A second vaccination program focused on a community-based approach in a low-

income community in New York City. The Start Right Coalition is a group of 23

organizations. The program is structured in line with community-based participatory

action research principles. Unique to this program is its work with already existing social

service and educational programs. Results of this campaign showed promising results.

From 2003-2007, the 80% rate of immunization in the target group equaled or exceeded

national rates for children ages 19 to 35-months old. The rate in 2007 then jumped up to

96.8%. Not only were rates far above the national average, but also the improvements

were maintained for five years. Investigators of the study did acknowledge that there

could have been a positive bias because they were able to carry out evaluations with more

satisfied than dissatisfied individuals (Findley et al., 2009).

The third health promotion program focusing on vaccination came from 2009

when there was a rapid spread of pandemic influenza A in New York. The attack rate

was high in school age children, leading the vaccination campaign to take place in the

schools. Although the program did not follow a health behavior model, there were three

different vaccination models. One used a school nurse, another used a school nurse plus

a contract nurse, and another used a team approach. Over 500,000 children were

vaccinated, making it NYCs largest school-based influenza vaccination program.

Challenges to this program included the coordination needed to carry out a program of

this size, and the underwhelming amount of parental consent obtained (Narcisco et al.,

2012).
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Health Promotion Program

The health promotion program that I would implement would be the Dont

Hesitate to Vaccinate Campaign. I think that this is appropriate for my change target

because many of these parents are delaying or refusing vaccinations. The program would

closely follow the Health Belief Model and use its two main constructs as the basis for its

interventions. The Dont Hesitate to Vaccinate Campaign would be directed at parents,

specifically mothers, before delivery of the baby. The goal would be to educate parents

in settings that they would frequent during the pregnancy, including doctor offices and

parenting classes.

The first construct of perceived threat is very crucial to the success of any

program tailored after the HBM. According to DiClemente et al., Health Belief Model

programs must find a way to inspire realistic perceptions of threat among the target

population (2013). As mentioned earlier, perceived severity and perceived susceptibility

both contribute to perceived threat. Parents today may not be aware of the severity of

some of these diseases because vaccines have made them much less common. Some

parents also may think that their child is unlikely to get the disease even if he or she is not

vaccinated. In one study, 90% of parents who neither delayed nor refused vaccines

thought that their child might get a disease if they werent vaccinated, while just 71% of

parents who delayed and refused vaccines thought that their child might get a disease if

not vaccinated (Smith et al., 2011).

To ensure that parents view refused vaccination as a real threat to their child, I

would use education and fear appeals. Education would involve information about

symptoms and side effects of the diseases that vaccines cover. Parents should also know
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about the concept of herd immunity and immunization rates in other countries. They

might perceive their child as being safe because everyone around them is vaccinated, but

statistics could show them just how many children are being exempt from vaccines and

how people from other countries may not be vaccinated. Fear appeals are messages that

show people a worst-case scenario of what could happen if they do or do not do what the

message says. They are intended to scare people into a certain health behavior. Because

people certainly become emotional over the health of their children, fear appeals may be

an effective way to persuade people. Images of sick children or real-life cases such as the

measles outbreak in San Diego mentioned earlier might change the level of perceived

threat (DiClemente et al., 2013).

The second major construct of expected net gain includes both increased

perceived value of benefits and decreased perceived barriers. Another reason why

parents may delay or refuse vaccinations is because they dont see the benefits, and dont

believe that vaccines are successful in preventing diseases (Smith et al., 2011).

Education for these parents again becomes crucial. It is important to stress the success of

vaccines in the past, and that this success may have kept them from even recognizing

some of the illnesses that children are vaccinated for today (CDC Sample key messages,

2014). Perceived barriers to vaccination could be the parents own ideas about the

vaccine. Parents might think that vaccines are unsafe or produce unwanted side effects

(Smith et al., 2011). Parents should be reminded that the United States currently has the

safest vaccine supply in its history, and that the risk of side effects are very small (CDC

Sample key messages, 2014). Myths about autism or other diseases related to vaccines

should be debunked by factual information and credible studies.

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One final factor that is very important to this change target is their relationship

and advice from a trusted health professional. Parents who delay or refuse vaccinations

are significantly less likely to report having a good relationship with their health care

provider than those who do not delay or refuse vaccines (88.5% vs. 94.2%, p<0.05)

(Smith et al., 2011). The CDC also states that health professionals remain parents most

trusted source of information about vaccines for their children (CDC Sample key

messages, 2014). For this reason, educating women at pre-natal appointments could be

very valuable. Depending on the setting, this could be done through public health nurses,

the clinic or hospital nurse, mid-level providers like a nurse practitioner, physicians

assistant, midwife, or the doctor.

Carrying out this program successfully would only be possible by using most or

all of the elements just described. Depending on the location of the program, it could be

implemented by public health professionals who work with city or state health

departments, or medical professionals such as public health nurses could also have a role.

These educators would go to existing services or educational programs like the successful

New York City vaccination program mentioned in the second health promotion program

example. Existing opportunities would occur in pre-natal classes and pre-natal visits at a

clinic or hospital. Mothers in this socioeconomic group might also be found at special

pregnancy workout classes at local gyms. I think it is important for contact with the

mother or parents to occur before the child is born, when they have more time to think

about the information. Also, parents should have made a decision by birth because the

hepatitis B vaccines first dose is at birth. The program would have the educators visit

these sites. They could have a small presentation set up with power points or other media
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tools. Additionally, pamphlets and other information from sources like the CDC should

be given out. It would be a wise decision to follow-up with these parents right before the

baby is due. Part of the HBM is using cues to action. The cue to action here could be a

short phone call or postcard reminder to have their baby vaccinated.

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References

Centers for Disease Control and Prevention. (2013). National, state, and local area

vaccination coverage among children aged 19-35 months-United States 2012.

Morbidity and Mortality Weekly Report. Retrieved from

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6236a1.htm?s_cid=m

m6236a1_e

Centers for Disease Control and Prevention. (2014). Protect your baby with

immunization. Retrieved from http://www.cdc.gov/features/infantimmunization/

Centers for Disease Control and Prevention. (2014). Sample key messages. Retrieved

from http://www.cdc.gov/vaccines/events/niiw/

Chen, M., Wang, R., Schneider, J., Tsai, C., Jiang, D., Hung, M., & Lin, L. (2011). Using

the health belief model to understand caregiver factors influencing childhood

influenza vaccinations. Journal Of Community Health Nursing, 28(1), 29-40.

doi:10.1080/07370016.2011.539087

DiClemente, R. J., Salazar, L. F., & Crosby, R. A. (2013). Health Behavior Theory for

Public Health. Burlington, MA: Jones & Bartlett Learning

Findley, S.E., Sanchez, M., Meija, M., Ferreira, R., Pena, O., Matos, S., Stockwell, M., &

Irigoyen, M. (2009). Effective strategies for integration immunization promotion

into community programs. Health Promotion Practice. 10(2). 128-137. Doi:

10.1177/15424839909331544

Narciso, H., Pathela, P., Morgenthau, B., Kansagra, S., May, L., Scaccia, A., & Zucker, J.

(2012). Description of a Large Urban School-Located 2009 Pandemic H1N1

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Vaccination Campaign, New York City 2009-2010. Journal Of Urban Health,

89(2), 317-328. doi:10.1007/s11524-011-9640-z

Peddecord, K., Jacobson, I., Engelberg, M., Kwizera, L., Macias, V., & Gustafson, K.

(2008). Can movie theater advertisements promote health behaviors? Evaluation

of a flu vaccination pilot campaign. Journal Of Health Communication, 13(6),

596-613.

Smith, P.J., Humiston, S.G., Hibbs, B. (2011). Parental delay or refusal of vaccine

doses, childhood vaccination coverage at 24 months of age, and the Health Belief

Model. Public Health Reports 126: 135-146.

The College of Physicians of Philadelphia. (2014). The history of vaccines. Retrieved

from http://www.historyofvaccines.org/content/timelines/all.