Advertisement

Development and beta-testing of the CONFIDENCE Intervention to increase pediatric COVID-19 vaccination

Open AccessPublished:November 16, 2022DOI:https://doi.org/10.1016/j.pedhc.2022.11.002

      Abstract

      Objective

      : Innovative strategies are needed to improve pediatric COVID-19 vaccination rates. We describe the process for developing a clinic-based intervention, CONFIDENCE, to improve pediatric COVID-19 vaccine uptake and present results of our beta-test for feasibility and acceptability.

      Methods

      : CONFIDENCE included communication training with providers, a poster campaign, and parent-facing educational materials. We assessed feasibility and acceptability through interviews and measured preliminary vaccine intention outcomes with a pre-post parent survey. Interviews were analyzed using rapid qualitative methods. We generated descriptive statistics for variables on the parent survey and used Fishers’ exact test to assess pre-post differences.

      Results

      : Participating providers (n=4) reported high levels of feasibility and acceptability with the intervention. We observed positive trends in parents’ (n=69) report of discussing vaccination with their provider and parental decision to accept COVID-19 vaccination.

      Conclusions

      : Our next steps will be to use more rigorous methods to establish efficacy and effectiveness of the CONFIDENCE intervention.

      Key words

      Introduction

      Despite COVID-19 vaccines being available to 12-17 year olds since May, 2021 and to 5-11 year olds since November, 2021, uptake of the vaccine series in this age group is sub-optimal. As of early September, 31% of 5-11 year olds and 61% of 12 to 17 year olds have completed the two-dose series and only 14% of 5-11 year olds and 29% of 12-17 year olds have received a booster (CDC, 2022). Vaccine hesitancy among parents is a primary factor driving these low rates of uptake (Alfieri et al., 2021; Rane et al., 2022, Scherer et al., 2021). Parents report safety concerns, fears about side effects, skepticism about the vaccine development and approval processes (Szilagyi et al., 2021), and the widespread perceptions that COVID-19 infection poses minimal risk to children and so the vaccine is unnecessary (Ruggiero et al., 2021). While combatting vaccine hesitancy will require collaboration across medical professionals, public health, and community organizations, research suggests that pediatricians will be the key messengers for parents. Parents have reported very high levels of trust in their child's pediatrician for information about the COVID-19 vaccine (Alfieri et al, 2021; Purvis et al, 2021; Scherer et al., 2021, Szilagyi et al, 2021), and many have reported a strong preference for their children to be vaccinated at their pediatrician's office (BLINDED FOR REVIEW; Scherer et al., 2021). Providers serving pediatric patients have echoed these sentiments, reporting that parents have expressed preferences for being able to bring their child to their primary care provider for the vaccine and wanting to hear from their own pediatricians about vaccine information (BLINDED FOR REVIEW).
      As the pandemic continues, vaccinating children and adolescents remains a priority to enable them to more safely return to social activities and to avoid potentially serious health complications related to COVID-19 infection (Barrett et al., 2021; Delahoy et al., 2021; Molteni et al., 2021; Zimmermann et al., 2022). Given that vaccine hesitancy has been a growing problem (He et al., 2022) and we already have strategies to address this hesitancy (Jarrett et al., 2015), the goal should be to draw from and adapt these strategies and evidence-based interventions that have been successful in addressing hesitancy around other vaccines (Ryan et al., 2022). Two emergent themes relevant to addressing COVID-19 vaccination are the critical role of the provider in parental communication (Elingson et al., 2022; Gilkey et al., 2016) and success of multicomponent interventions (Jarrett et al., 20215). Thus, to increase parental confidence in COVID-19 vaccination and increase pediatric vaccination rates, these strategies and interventions need to be adapted for relevance to the unique and urgent context that we are currently experiencing.
      Informed by rapid qualitative research conducted by our team and adaptation of evidence-based strategies developed for other vaccines, our team developed and implemented a multi-component practice-based intervention, CONFIDENCE: Clinicians for Effective COVID-19 Vaccine Conversations for Youth and Adolescents, to support healthcare providers in having conversations with vaccine hesitant and resistant parents. The purpose of this paper is to describe the development process and results of the beta-test of the CONFIDENCE intervention.

      Methods

      Intervention Development Process

      The CONFIDENCE intervention development drew from formative qualitative research with pediatricians and parents, and review and adaptation of existing evidenced-based interventions in response to themes identified in the formative work.

      Provider Interviews and Family Focus Groups

      We conducted 16 semi-structured interviews with pediatric and family medicine providers practicing in Central and Western Massachusetts (BLINDED FOR REVIEW). The purpose of these interviews was to explore the perspectives of these providers and their efforts to vaccinate youth against COVID-19. We also held a total of 10 focus groups with 78 parents from Worcester, Massachusetts (BLINDED FOR REVIEW) .Seven of these focus groups included parent/guardians of 5- to 11-year-old children and 3 included parents/guardians of 12- to 17-year-old children. The focus group questions were designed to explore parents' perceptions of COVID-19 vaccination for their children. Topics covered included motivators and demotivators to vaccination, perceived impact of COVID-19, and influences on vaccine decision making. Trusted community partners recruited for focus groups which were held in English (n=6) and Spanish (n=4). We used rapid qualitative analysis to analyze interview and focus group data (Vindrola-Padros & Johnson, 2020). The resulting themes were translated into intervention components as outlined in Figure 1.

      Identification and Adoption of Evidence Based Interventions from Other Vaccines

      We harnessed the expertise of our team in behavioral interventions and HPV vaccination to identify and adapt relevant evidence-based interventions for use with COVID-19 in response to themes identified in our formative qualitative work. Through literature review and team discussion, we designed an intervention that includes posters of selected personal vaccine stories (Perkins et al., 2020), a provider-delivered counseling algorithm that includes a strong presumptive recommendation (Gilkey et al., 2016) and motivational interviewing principles (Miller & Rose, 2009), and patient-facing materials as the key components of our intervention. We also designed a webinar to train providers in the delivery of the counseling component of the intervention.

      CONFIDENCE Intervention

      As shown in Figure 1 the confidence intervention consists of three key components, a 3-step communication training for providers, provider “my reasons why’ poster campaign, and parent facing educational materials.

      3-Step Communication Training

      We held a 1-hour online training in which we gave an overview of COVID-19 vaccine data, current vaccination rates, described the CONFIDENCE intervention and demonstrated the provider counseling component via role-playing videos. The CONFIDENCE counseling algorithm involves (1) a strong presumptive provider recommendation such as “All of our providers are committed to keeping your child as safe as possible from COVID-19 infection, so we are strongly recommending that all our patients get the vaccine as soon as possible. We can do that today at the end of your visit", (2) assess vaccine readiness and identify whether parent is hesitant or resistant, deliver tailored assistance, and plan follow up using motivational interviewing principles, (3) and sharing providers’ personal vaccine stories. The approach is intended to encourage hesitant parents, be collaborative, and not alienate resistant parents. Six providers (50% of clinic providers) attended the training.

      Provider “My reasons why” Posters

      For all interested providers, including nursing staff and residents, we held sessions with a professional photographer to take portraits and a research team member worked with providers to develop their vaccine stories centered on their personal vaccination motivations. For example, one pediatrician shared the following:
      I have 10-year-old twins that have asthma and a five-year-old. I got my children vaccinated to protect them and their grandparents. They all got their first dose at school and my 5-year-old got it on his birthday and proudly told everyone it was his first birthday present!”
      These photographs and personal vaccine stories were used to create custom posters supporting COVID-19 vaccination which were displayed throughout the clinic.

      Parent-Facing Educational Materials

      During the 1-hour online provider training, we also introduced providers to our parent-facing educational materials. These educational materials were developed to address common questions and concerns raised by parents during the formative focus groups. Educational materials included a trifold fact sheet infographic with Q&A regarding COVID-19 vaccination for 5–11-year-old children and a single page fact sheet with general COVID-19 vaccine information for all age groups. We supplied these educational materials in 9 languages (English, Spanish, Portuguese, Vietnamese, Haitian Creole, Swahili, Pashto, Dari, Farsi) and kept them stocked in the exam rooms of the clinic throughout the beta testing period.

      Beta-test and evaluation

      We beta-tested the CONFIDENCE intervention in a pediatric primary care clinic associated with an academic medical center and the largest not for profit healthcare system in Central Massachusetts over a two-month period. The clinic was recruited through professional connections within our institution. In this process we identified a provider who served as the physician champion for this project and assisted with dissemination of materials and implementation logistics. The clinic began administering COVID-19 vaccines in July 2021 and has administered an average of 176 COVID-19 vaccines per month between July 2021 and April 2022.

      Study Design

      We used a mixed-methods approach to evaluate the CONFIDENCE intervention, employing both provider interviews and pre-post parent surveys. Our Institutional Review Board determined that this project was not human subjects’ research.

      Measures

      Our primary measures were feasibility and acceptability for providers and parents. We conducted mid-point provider interviews four weeks post training. Our team emailed all the providers (n=6) who completed the webinar training to request participating in short interview via phone or video conferencing. We developed an interview guide to assess the following: participation in CONFIDENCE intervention components, acceptability, feasibility, as well as barriers and facilitators to implementation.
      Acceptability was also assessed through parent surveys. These pre-post parent surveys (available in English, Spanish and Portuguese) were completed by parents/guardians after well-child visits. In addition to acceptability, surveys also assessed: demographic information about the parent and child; parent's COVID-19 vaccination status, child's COVID-19 vaccination status, satisfaction with conversation with provider about COVID-19 vaccination, and future COVID-19 vaccine intentions for child. Survey data collection began approximately two weeks prior to the webinar training which comprised the pre-test and continued for another eight weeks after the training which comprised the post-test.

      Analysis

      To analyze interview data, we used rapid qualitative methods (Vindrola-Padros & Johnson, 2020). We developed a summary template using the primary topics addressed in the interview guide and two team members (NAMES BLINDED) completed a summary for one interview and then met to discuss and resolve any discrepancies. Through this process we added an additional domain to the template and then one team member (NAME BLINDED) completed the remaining template summaries. These summaries were then organized into a matrix of domains and participants. For survey data we generated frequencies and descriptive statistics. To account for small sample sizes, we used Fisher's exact test to explore pre-post differences.

      Results

      Parent Surveys

      In total, 106 parents completed the survey, of which 65.1% reported that their children were under-vaccinated (n=69), defined as 0 or 1 doses for children ages 5 to 11 and 0, 1, or 2 doses for children ages 12 to 17. Children under age 12 did not became eligible for a booster dose until May 19th, 2022, therefore, to remain consistent with the recommendations at the start of the beta test we classified children ages 5 to 11 with two doses of the vaccine series as being “up-to-date”. Demographic characteristics and vaccine-status for the pre and post-test sample are presented in Table 1. Only survey responses for parents of children classified as “under-vaccinated” are reported. Parents in both the pre and post-test samples predominantly spoke English, identified as female and had received two doses of the COVID-19 vaccine.
      Table 1Comparisons of demographic and vaccine status for under-vaccinated children pre- and post-intervention implementation, CONFIDENCE beta test, Worcester, MA, 2022 (n=69).
      Response optionsPrePost
      n(%)n(%)
      Language of survey*English26(83.3)37(94.9)
      Spanish5(16.7)2(5.1)
      Parents’ genderMale5(16.7)5(20.5)
      Female25(83.3)26(76.5)
      Parents’ RaceBlack/African American4(13.3)12(30.1)
      White**20(66.7)10(25.6)
      Other4(13.3)13(33.3)
      Parents’ ethnicityHispanic/Latino14(50)11(31.5)
      Parent vaccine doses received0 doses8(27.6)6(16.2)
      1 dose4(13.8)4(10.8)
      2 doses9(31.0)19(51.4)
      3 doses8(27.6)8(21.6)
      Did you see posters promoting COVID-19 vaccine in clinic?Yes21(77.8)26(78.8)
      No6(22.2)7(21.2)
      Child genderMale17(58.6)19(50.0)
      Female12(41.4)19(50.0)
      Black/African American4(13.3)10(25.6)
      White16(53.3)11(28.2)
      Other6(20.0)14(35.9)
      Child's ethnicity

      Hispanic/Latino16(59.3)12(36.4)
      Child's age5-1112(40.0)14(35.9)
      12-1718(60.0)25(64.1)
      *Survey also available in Portuguese but we only received responses in English and Spanish
      ** Indicates statistically significant difference <.05
      Parental responses regarding the questions about their interaction with the provider about the COVID-19 vaccine are presented in Table 2. Of note, parental report of provider discussing COVID-19 vaccination, provider sharing personal vaccines story, and satisfaction with COVID-19 vaccine conversation were all higher in the post-test sample.
      Table 2Differences in experiences with provider and COVID-19 vaccine recommendation and vaccine intentions pre and post intervention implementation, CONFIDENCE beta test, Worcester, MA, 2022 (n=69).
      Response optionsPre n(%)Post n(%)Change in Percentage
      Did the provider discuss COVID-19 vaccination today?Yes26(86.7)38(97.4)+10.7
      Did the provider share their own COVID-19 vaccine experience with you?Yes18(60.0)28(71.8)+11.8
      How satisfied were you with the conversation about COVID-19 vaccination for your child?Very Satisfied19(73.1)32(84.2)+11.1
      Somewhat Satisfied5(19.2)5(13.2)-6.0
      Not satisfied2(7.7)1(2.6)-5.1
      Did the provider give you any materials about COVID-19 vaccination today?Yes14(48.3)24(61.5)+13.2
      If yes, how satisfied were you with those materials? (out of n=35)Very satisfied11(84.6)19(86.4)+1.8
      Somewhat satisfied2(40.0)3(60.0)+20.0
      Not satisfied0(0.0)0(0.0)
      Do you still have unanswered questions about COVID-19 vaccination?Yes2(7.1)2(5.3)-1.8
      Did you decide to vaccinate your child today?Yes12(44.4)24(61.5)+17.1
      If you did not decided to vaccinate, how likely do you think you are to vaccinate your child in the future? (out of n=30)*Very likely6(46.2)2(16.7)-29.5
      Somewhat likely2(15.4)9(75.0)+59.6
      Not likely5(38.5)1(8.3)-30.2
      *Indicates statistically significant difference <.05

      Provider Interviews

      We completed interviews between late April and early May, 2022 (n=4) with providers who had participated in the webinar training. Results are organized below by the following themes which emerged through the rapid qualitative analysis: participation in intervention components, feasibility, acceptability, and suggested adaptations.

      Participation in Intervention Components

      All providers reported participating in several of the intervention components; all attended the webinar, and three out of four shared their personal vaccine story on a poster. The provider who did not participate in the poster campaign noted “I have not had my photo taken yet, because the idea of seeing myself on that larger poster seems unappealing.”

      Feasibility

      Overall, providers reported that participating in the CONFIDENCE intervention was easy, straightforward, and did not require a lot of their time. One provider said that they appreciated that the training webinar was held during a regularly scheduled meeting, so it was not an additional burden to attend. Barriers reported by providers were related to implementing the parent surveys and use of the parent facing educational materials. As one provider noted it was difficult to remember to give the survey to parents because providers are “so busy doing so many things.” In relation to the educational materials provided, another provider noted that “it's always good to have...the more education the better” but also said they did not always remember the materials were in the exam rooms and available to distribute to parents. In fact, all of the providers interviewed reported that they rarely used the educational materials and would need more reminders or easier access to the materials to integrate them into routine practice.

      Acceptability

      All providers interviewed reported high levels of acceptability with the intervention overall and with the specific components. Generally, providers found the webinar training to be useful, though as one noted “I do remember using it, at least with some patients that day, so I think it wasn't necessarily new things, but it was stuff that's definitely helpful to have reinforced.” There was also a sentiment shared by all those interviewed that it was “nice to have some, you know, external excitement about getting the messages out and things like that.”

      Suggested Adaptations

      Finally, several participants offered reflections on adaptations or improvements to the intervention and implementation based on their experiences. These suggestions were primarily related to the parent-facing educational materials. Several participants noted that it has been difficult to stay up-to-date with the evolving recommendations and approvals for COVID-19 vaccination and that having regularly updated materials or talking points would be helpful. In response to the challenges in integrating materials into conversations with parents, one participant suggested that if the materials were available electronically, they could be integrated into patients’ after-visit summary report and that may be a better means of dissemination.

      Discussion

      The results of our beta-test of the CONFIDENCE intervention suggest that this approach has promise to support pediatric clinics in their efforts to promote COVID-19 vaccination. Specifically, intervention participants reported high levels of feasibility and acceptability of participating in the intervention and our survey data suggests positive trends in improving vaccine acceptance. However, we encountered several challenges related to implementing the CONFIDENCE intervention that will need to be addressed before conducting a larger-scale trial of the intervention.
      We found promising results in terms of feasibility and acceptability as well as outcomes in the parent surveys. The principal component of the intervention was the 3-step communication training outlining the provider-delivered counseling algorithm that had a goal of empowering providers to improve communication with hesitant and resistant parents. The training outlined a process of giving a strong recommendation for the COVID-19 vaccine (Gilkey et al., 2016), followed by assessing vaccine readiness, exploring ambivalence, delivering tailored assistance and planning follow-up using motivational interviewing principles (Miller & Rose, 2009), and sharing a personal vaccine experience, if possible, their own child's vaccination experience (Massey et al., 2021; Perkins et al., 2020). Overall, providers reported high acceptability of this approach and ease of use in integrating it into their everyday practice. Increasingly, there is literature suggesting that the approaches used in our approach may be appropriate to reduce hesitancy around COVID-19 vaccination (Garbarda & Butterworth, 2021; Rutten et al., 2021). However, to date, we have not found established evidence on the effectiveness of combining these three approaches specifically for COVID-19 vaccine promotion in a pediatric population. In addition to our communication algorithm being acceptable to providers, there was also evidence of adoption of at least some of these strategies in the results from the parent survey. While our study was not powered to detect statistically significant pre-post differences, on nearly all measures related to the conversation with the provider about vaccination we saw more positive results in the post-test group. Importantly, we found that a higher percentage of parents in the post-test group reported their pediatrician discussed COVID-19 vaccination at the visit, that the pediatrician shared their personal vaccine story, and that they had made the decision to vaccinate their child at the appointment. Together these findings suggest successful integration of the training components into routine clinical practice
      Challenges related to both the implementation of the CONFIDENCE intervention as intended as well as to our data collection process were identified. Related to implementation, providers reported not using or distributing the educational materials to parents. The parent-facing educational materials (fact sheets and tri-fold brochures) were available in all exam rooms, however, as one provider noted, simply making them available was not sufficient. To ensure broader dissemination of these materials, one strategy, as suggested by one of the providers in our study, may be to integrate them into electronic health record platforms so that providers could attach them to patients’ visit summaries. In terms of data collection, one logistical challenge we encountered was related to distribution of the surveys. The providers were responsible for distributing the survey to parents after their visit, however, as all the providers we interviewed noted, they did not always remember to do this. Moving forward, a more streamlined approach to data collection will be needed to ensure sufficient sample size to establish efficacy, and ultimately, effectiveness of this intervention. To resolve both of these challenges, one potential solution could be to use workflow mapping (Ozkaynak et al., 2013) to identify alternative options for survey dissemination and integrating the parent-facing materials into visits. It is likely that all clinics will have different processes for this and thus, implementation will need to be tailored to be appropriate for specific clinic workflows to ensure data collection is completed.
      To date, the majority of the literature on pediatric COVID-19 vaccination has focused on understanding parental intentions (Scherer et al., 2021; Szilagyi et al., 2021) and factors affecting those intentions (Head et al, 2022; Rogers et al., 2021; Walker et al., 2021). Moreover, much of the literature on interventions to promote COVID-19 vaccination has explored either policy interventions (i.e. mandates (Mello et al., 2022; Sprengholz et al., 20220) and incentives, (Thirumurthy et al., 2021) or mass communication strategies (i.e. text messages, emails, social media) (Freeman et al., 2021; Saantos et al., 2021)). However, there have been few reports of clinic-based and provider-focused interventions that focus on reducing parental hesitancy for COVID-19 vaccination. While a multi-level approach that includes policy and communication approaches will be needed to encourage hesitant and resistant parents to vaccinate their children, previous literature on pediatric vaccine interventions has identified that providers are critical to vaccination efforts.(Frew et al., 2017; Oh et al., 2021). As COVID-19 vaccination rates in the pediatric population remain low, identifying these best practices and building an evidence base around clinic-focused interventions should be a priority. Our future research will prioritize adapting and further testing the CONFIDENCE intervention to support pediatric practices in these efforts.

      Strengths and limitations

      The primary strength of our approach for the CONFIDENCE intervention is that development and implementation was directly informed by our team's formative qualitative research (BLINDED FOR REVIEW) as well as existing evidence-based practices to promote vaccination (Ellingson et al., 2022; Gilkey et al., 2016). Additionally, the use of rapid qualitative methods both in our formative work and our evaluation of the beta-test allowed us to be responsive to current context by moving from intervention development to implementation, evaluation, and dissemination in under a year (Vinrola-Padros & Johnson, 2020).
      However, our results are subject to certain limitations. We completed the beta-test in a single pediatric clinic within an academic medical center setting and thus we are unsure how this approach would translate in a community clinical setting. Moreover, since our goal was to establish feasibility and acceptability, we did not design this study to be powered to detect significant pre-posttest differences. Our ability to explore potential intervention effects was also limited by the challenges providers experienced in collecting survey data. Finally, it is important to note that parents’ levels of hesitancy are dynamic and while our intervention took place over a short time period (10 weeks) it is possible that the positive results we observed in vaccine acceptance could be due, in part, to changing public sentiments. Despite these limitations, we are encouraged by the positive results observed in this beta-test, and believe that future randomized clinical trials are warranted to establish stronger evidence for the CONFIDENCE intervention.

      Conclusions

      In our beta-test of the CONFIDENCE intervention, we found high levels of feasibility and acceptability among participating providers, as well as encouraging data from pre-post parent surveys. Despite the importance of clinic-based and provider-focused interventions for pediatric COIVD-19 vaccination uptake, to date there have been few reports of efforts in this area. Moreover, it is clear that COVID-19 vaccination will continue to be an important topic to address in the future as rates of uptake for pediatric populations remain lower than any other age group (CDC, 2022). As additional vaccines and boosters become available and recommended, supporting and empowering providers in their efforts to counsel vaccine hesitant and resistant parents will be crucial to protect children and adolescents from the negative effects of the COVID-19 infection. Next steps will be to further test the CONFIDENCE intervention using more rigorous study designs and in community settings in order to establish efficacy for increasing parents’ intentions to vaccinate their children.

      References

      • 1
        Alfieri, N. L., Kusma, J. D., Heard-Garris, N., Davis, M. M., Golbeck, E., Barrera, L., & Macy, M. L. (2021). Parental COVID-19 vaccine hesitancy for children: vulnerability in an urban hotspot. BMC public health21(1), 1662. https://doi.org/10.1186/s12889-021-11725-5
      • 2
        Barrett, C. E., Koyama, A. K., Alvarez, P., Chow, W., Lundeen, E. A., Perrine, C. G., Pavkov, M. E., Rolka, D. B., Wiltz, J. L., Bull-Otterson, L., Gray, S., Boehmer, T. K., Gundlapalli, A. V., Siegel, D. A., Kompaniyets, L., Goodman, A. B., Mahon, B. E., Tauxe, R. V., Remley, K., & Saydah, S. (2022). Risk for Newly Diagnosed Diabetes >30 Days After SARS-CoV-2 Infection Among Persons Aged <18 Years - United States, March 1, 2020-June 28, 2021. MMWR. Morbidity and mortality weekly report71(2), 59–65. https://doi.org/10.15585/mmwr.mm7102e2
      • 3
        Centers for Disease Control and Prevention. COVID Data Tracker. Atlanta, GA: US Department of Health and Human Services, CDC; 2022, September 09. https://covid.cdc.gov/covid-data-tracker
      • 4
        Delahoy, M. J., Ujamaa, D., Whitaker, M., O'Halloran, A., Anglin, O., Burns, E., Cummings, C., Holstein, R., Kambhampati, A. K., Milucky, J., Patel, K., Pham, H., Taylor, C. A., Chai, S. J., Reingold, A., Alden, N. B., Kawasaki, B., Meek, J., Yousey-Hindes, K., Anderson, E. J., … COVID-NET Surveillance Team (2021). Hospitalizations Associated with COVID-19 Among Children and Adolescents - COVID-NET, 14 States, March 1, 2020-August 14, 2021. MMWR. Morbidity and mortality weekly report70(36), 1255–1260. https://doi.org/10.15585/mmwr.mm7036e2
      • 5
        Ellingson, M. K., Bednarczyk, R. A., O'Leary, S. T., Schwartz, J. L., Shapiro, E. D., & Niccolai, L. M. (2022). Understanding the Factors Influencing Health Care Provider Recommendations about Adolescent Vaccines: A Proposed Framework. Journal of behavioral medicine, 1–10. Advance online publication. https://doi.org/10.1007/s10865-022-00296-4
      • 6
        Freeman, D., Loe, B. S., Yu, L. M., Freeman, J., Chadwick, A., Vaccari, C., Shanyinde, M., Harris, V., Waite, F., Rosebrock, L., Petit, A., Vanderslott, S., Lewandowsky, S., Larkin, M., Innocenti, S., Pollard, A. J., McShane, H., & Lambe, S. (2021). Effects of different types of written vaccination information on COVID-19 vaccine hesitancy in the UK (OCEANS-III): a single-blind, parallel-group, randomised controlled trial. The Lancet. Public health6(6), e416–e427. https://doi.org/10.1016/S2468-2667(21)00096-7
      • 7
        Frew, P. M., & Lutz, C. S. (2017). Interventions to increase pediatric vaccine uptake: An overview of recent findings. Human vaccines & immunotherapeutics13(11), 2503–2511. https://doi.org/10.1080/21645515.2017.1367069
      • 8
        Gabarda, A., & Butterworth, S. W. (2021). Using Best Practices to Address COVID-19 Vaccine Hesitancy: The Case for the Motivational Interviewing Approach. Health promotion practice22(5), 611–615. https://doi.org/10.1177/15248399211016463
      • 9
        Gilkey, M. B., Calo, W. A., Moss, J. L., Shah, P. D., Marciniak, M. W., & Brewer, N. T. (2016). Provider communication and HPV vaccination: The impact of recommendation quality. Vaccine34(9), 1187–1192. https://doi.org/10.1016/j.vaccine.2016.01.023
      • 10
        BLINDED FOR REVIEW-Published in Human Vaccines and Immunotherapeutics
      • 11
        He, K., Mack, W. J., Neely, M., Lewis, L., & Anand, V. (2022). Parental Perspectives on Immunizations: Impact of the COVID-19 Pandemic on Childhood Vaccine Hesitancy. Journal of community health47(1), 39–52. https://doi.org/10.1007/s10900-021-01017-9
      • 12
        Head, K. J., Zimet, G. D., Yiannoutsos, C. T., Silverman, R. D., Sanner, L., & Menachemi, N. (2022). Factors that differentiate COVID-19 vaccine intentions among Indiana parents: Implications for targeted vaccine promotion. Preventive medicine158, 107023. https://doi.org/10.1016/j.ypmed.2022.107023
      • 13
        Jarrett, C., Wilson, R., O'Leary, M., Eckersberger, E., Larson, H. J., & SAGE Working Group on Vaccine Hesitancy (2015). Strategies for addressing vaccine hesitancy - A systematic review. Vaccine33(34), 4180–4190. https://doi.org/10.1016/j.vaccine.2015.04.040
      • 14
        Massey, P. M., Togo, E., Chiang, S. C., Klassen, A. C., Rose, M., Manganello, J. A., & Leader, A. E. (2021). Identifying HPV vaccine narrative communication needs among parents on social media. Preventive medicine reports23, 101488. https://doi.org/10.1016/j.pmedr.2021.101488
      • 15
        Miller, W. R., & Rose, G. S. (2009). Toward a theory of motivational interviewing. The American psychologist64(6), 527–537. https://doi.org/10.1037/a0016830
      • 16
        Mello, M. M., Opel, D. J., Benjamin, R. M., Callaghan, T., DiResta, R., Elharake, J. A., Flowers, L. C., Galvani, A. P., Salmon, D. A., Schwartz, J. L., Brewer, N. T., Buttenheim, A. M., Carpiano, R. M., Clinton, C., Hotez, P. J., Lakshmanan, R., Maldonado, Y. A., Omer, S. B., Sharfstein, J. M., & Caplan, A. (2022). Effectiveness of vaccination mandates in improving uptake of COVID-19 vaccines in the USA. Lancet (London, England)400(10351), 535–538. https://doi.org/10.1016/S0140-6736(22)00875-3
      • 17
        Molteni, E., Sudre, C. H., Canas, L. S., Bhopal, S. S., Hughes, R. C., Antonelli, M., Murray, B., Kläser, K., Kerfoot, E., Chen, L., Deng, J., Hu, C., Selvachandran, S., Read, K., Capdevila Pujol, J., Hammers, A., Spector, T. D., Ourselin, S., Steves, C. J., Modat, M., … Duncan, E. L. (2021). Illness duration and symptom profile in symptomatic UK school-aged children tested for SARS-CoV-2. The Lancet. Child & adolescent health5(10), 708–718. https://doi.org/10.1016/S2352-4642(21)00198-X
      • 18
        Oh, N. L., Biddell, C. B., Rhodes, B. E., & Brewer, N. T. (2021). Provider communication and HPV vaccine uptake: A meta-analysis and systematic review. Preventive medicine148, 106554. https://doi.org/10.1016/j.ypmed.2021.106554
      • 19
        Ozkaynak, M., Brennan, P. F., Hanauer, D. A., Johnson, S., Aarts, J., Zheng, K., & Haque, S. N. (2013). Patient-centered care requires a patient-oriented workflow model. Journal of the American Medical Informatics Association: JAMIA20(e1), e14–e16. https://doi.org/10.1136/amiajnl-2013-001633
      • 20
        Perkins, R. B., Banigbe, B., Fenton, A. T., O'Grady, A. K., Jansen, E. M., Bernstein, J. L., Joseph, N. P., Eun, T. J., Biancarelli, D. L., & Drainoni, M. L. (2020). Effect of a multi-component intervention on providers' HPV vaccine communication. Human vaccines & immunotherapeutics16(11), 2736–2743. https://doi.org/10.1080/21645515.2020.1747923
      • 21
        Purvis, R. S., Hallgren, E., Moore, R. A., Willis, D. E., Hall, S., Gurel-Headley, M., & McElfish, P. A. (2021). Trusted Sources of COVID-19 Vaccine Information among Hesitant Adopters in the United States. Vaccines9(12), 1418. https://doi.org/10.3390/vaccines9121418
      • 22
        Rane, M. S., Robertson, M. M., Westmoreland, D. A., Teasdale, C. A., Grov, C., & Nash, D. (2022). Intention to Vaccinate Children Against COVID-19 Among Vaccinated and Unvaccinated US Parents. JAMA pediatrics176(2), 201–203. https://doi.org/10.1001/jamapediatrics.2021.5153
      • 23
        Rogers, A. A., Cook, R. E., & Button, J. A. (2021). Parent and Peer Norms are Unique Correlates of COVID-19 Vaccine Intentions in a Diverse Sample of U.S. Adolescents. The Journal of adolescent health: official publication of the Society for Adolescent Medicine, 69(6), 910–916. https://doi.org/10.1016/j.jadohealth.2021.09.012
      • 24
        Ruggiero, K. M., Wong, J., Sweeney, C. F., Avola, A., Auger, A., Macaluso, M., & Reidy, P. (2021). Parents' Intentions to Vaccinate Their Children Against COVID-19. Journal of pediatric health care: official publication of National Association of Pediatric Nurse Associates & Practitioners35(5), 509–517. https://doi.org/10.1016/j.pedhc.2021.04.005
      • 25
        Rutten, L. J., Zhu, X., Leppin, A. L., Ridgeway, J. L., Swift, M. D., Griffin, J. M., St Sauver, J. L., Virk, A., & Jacobson, R. M. (2021). Evidence-Based Strategies for Clinical Organizations to Address COVID-19 Vaccine Hesitancy. Mayo Clinic proceedings96(3), 699–707. https://doi.org/10.1016/j.mayocp.2020.12.024
      • 26
        BLINDED FOR REVIEW-published in Preventive Medicine Reports
      • 27
        Ryan, G., Askelson, N. M., Miotto, M. B., Goulding, M., Rosal, M. C., Pbert, L., & Lemon, S. C. (2022). Lessons Learned From Human Papillomavirus Vaccination to Increase Uptake of Adolescent COVID-19 Vaccination. The Journal of adolescent health: official publication of the Society for Adolescent Medicine70(3), 359–360. https://doi.org/10.1016/j.jadohealth.2021.11.025
      • 28
        Santos, H. C., Goren, A., Chabris, C. F., & Meyer, M. N. (2021). Effect of Targeted Behavioral Science Messages on COVID-19 Vaccination Registration Among Employees of a Large Health System: A Randomized Trial. JAMA network open4(7), e2118702. https://doi.org/10.1001/jamanetworkopen.2021.18702
      • 29
        Scherer, A. M., Gedlinske, A. M., Parker, A. M., Gidengil, C. A., Askelson, N. M., Petersen, C. A., Woodworth, K. R., & Lindley, M. C. (2021). Acceptability of Adolescent COVID-19 Vaccination Among Adolescents and Parents of Adolescents - United States, April 15-23, 2021. MMWR. Morbidity and mortality weekly report70(28), 997–1003. https://doi.org/10.15585/mmwr.mm7028e1
      • 30
        Sprengholz, P., Korn, L., Eitze, S., Felgendreff, L., Siegers, R., Goldhahn, L., De Bock, F., Huebl, L., Böhm, R., & Betsch, C. (2022). Attitude toward a mandatory COVID-19 vaccination policy and its determinants: Evidence from serial cross-sectional surveys conducted throughout the pandemic in Germany. Vaccine, S0264-410X(22)00130-X. Advance online publication. https://doi.org/10.1016/j.vaccine.2022.01.065
      • 31
        Szilagyi, P. G., Shah, M. D., Delgado, J. R., Thomas, K., Vizueta, N., Cui, Y., Vangala, S., Shetgiri, R., & Kapteyn, A. (2021). Parents' Intentions and Perceptions About COVID-19 Vaccination for Their Children: Results From a National Survey. Pediatrics148(4), e2021052335. https://doi.org/10.1542/peds.2021-052335
      • 32
        Thirumurthy, H., Milkman, K. L., Volpp, K. G., Buttenheim, A. M., & Pope, D. G. (2022). Association between statewide financial incentive programs and COVID-19 vaccination rates. PloS one17(3), e0263425. https://doi.org/10.1371/journal.pone.0263425
      • 33
        Vindrola-Padros, C., & Johnson, G. A. (2020). Rapid Techniques in Qualitative Research: A Critical Review of the Literature. Qualitative health research30(10), 1596–1604. https://doi.org/10.1177/1049732320921835
      • 34
        Walker, K. K., Head, K. J., Owens, H., & Zimet, G. D. (2021). A qualitative study exploring the relationship between mothers' vaccine hesitancy and health beliefs with COVID-19 vaccination intention and prevention during the early pandemic months. Human vaccines & immunotherapeutics17(10), 3355–3364. https://doi.org/10.1080/21645515.2021.1942713
      • 35
        Zimmermann, P., Pittet, L. F., & Curtis, N. (2022). Long covid in children and adolescents. BMJ (Clinical research ed.)376, o143. https://doi.org/10.1136/bmj.o143

      Ethics Statement

      Authors have no conflicts of interest to declare. This work was reviewed by our Institutional Review Board and determined to not be human subjects’ research.

      Conflicts of Interest

      None to disclose

      Acknowledgements

      This work was supported by a cooperative agreement 5-U48-DP-005031 from the Centers for Disease Control and Prevention . GWR is supported by National Cancer Institute Grant #T32 CA172009 MG is supported by the National Center for Advancing Translational Sciences, National Institutes of Health TL1TR001454 and the National Heart, Lung, and Blood Institutes of Health F31HL164126 . Funders had no involvement in this project.