Research article
Open Access

Identifying Medical Residents’ Perceived Needs in Vaccine Education though a Needs Assessment Survey

Sarah Williams[1], Shannon Clark[2], Sharon Humiston[2], Barbara Pahud[2], Donald Middleton[3], Kadriye Lewis[2]

Institution: 1. Vanderbilt University School of Medicine, 2. Children's Mercy Hospital, 3. University of Pittsburgh
Corresponding Author: Dr Sarah Williams ([email protected])
Categories: Curriculum Planning, Research in Health Professions Education, Undergraduate/Graduate
Published Date: 10/03/2020

Abstract

Background: Vaccine education during residency is not standardized. Little is known about resident perspectives on vaccines and ideal vaccine training.

 

Methods: A convenience sample of pediatric and family medicine (FM) residents were surveyed using a de novo 22 question survey to understand perspectives on vaccines and current and preferred vaccine education curriculum. Responses were analyzed categorically and compared by resident year using Fisher’s Exact test.

 

Results: In October 2016, 126 residents from 9 pediatric and FM programs completed the survey. Resident respondents’ training levels varied. Most were 25-29 years old and female. High familiarity with vaccines and agreeing to defer recommended vaccine(s) increased with additional years of training (p<0.01). Most residents want to learn more about vaccine risks, benefits, and communication skills. Preferred training modalities were in-person lectures, online modules, and continuity clinic didactics. Residents rated MMR and Hib vaccines as “highly important” more frequently than they did so for HPV and influenza vaccines. One fifth of respondents reported some degree of hesitancy regarding vaccines.

 

Conclusion: Results provide insight on framework and scope for development of a vaccine education curriculum. Identification of vaccine hesitancy among residents and the rating of certain recommended vaccines as of variable importance underscores the need for resident vaccine training.

 

Keywords: Vaccine education; Vaccine safety; Vaccine hesitancy; Needs assessment; Resident vaccine education

Introduction

Parents are increasingly delaying or refusing vaccines for their children and/or themselves (Siddiqui, Salmon and Omer, 2013). Communities with high rates of under-vaccination have higher rates of vaccine preventable disease (Glanz et al., 2009; Glanz et al., 2010; McCarthy, 2015). Primary care physicians need to be prepared to discuss vaccines with hesitant parents in order to optimize vaccination rates. However, standardized evidence-based residency training to manage ‘vaccine hesitancy’ has not been developed. A 2014 survey of Association of Pediatric Program Directors members showed that most pediatric training programs lacked an organized curriculum on vaccine safety or parental vaccine hesitancy, yet most respondent program directors believed such training would be valuable and important (Williams and Swan, 2014). Further, it is unknown whether residents harbor vaccine hesitant attitudes similar to the general population, which would undermine their vaccine recommendations.

 

In 2016, our team surveyed pediatric and family medicine (FM) residents to understand their perspectives on vaccination and desired vaccine training. Our goal was to assess the need and structure for the development of an evidence-based vaccine education curriculum for residents by examining residents’ confidence, attitudes, hesitancy and training needs related to vaccines.

Methods

This study utilized a needs assessment survey to gauge/obtain pediatric and family medicine residents’ needs in vaccine education in the US. Our study was approved by the Institutional Review Board of Children’s Mercy Kansas City.

 

Setting.  In October 2016, we surveyed residents from a convenience sample of US pediatric and FM residency programs. Programs were identified through outreach by team investigators.

 

Survey tool.  We developed the resident survey using an iterative approach. First, the overarching goal of the survey was determined: assessment of knowledge, attitudes, confidence, hesitancy regarding vaccines, and preference for training format. All potential questions were developed de novo and reviewed by the co-authors for relevancy and understandability. Draft survey items were then piloted with a small sample of pediatric residents from a single institution and their feedback was incorporated as appropriate.

 

The final survey included 22 questions on perceived vaccine importance, vaccine familiarity, vaccine attitudes, vaccine hesitancy, comfort level in communicating with patients and parents about vaccines, current vaccine training, preferred vaccine educational content, and preferred modalities for training. Most questions were formatted using 3 to 5-point Likert scales. Questions evaluating preferred vaccine educational content, current vaccine training, and preferred training modalities included several response options whereby respondents could select more than one choice. Several questions included optional open-ended response options for “other comments”. The survey also included 6 demographic questions (resident type, institution, race/ethnicity, age, gender, and program training year).

 

Data Collection. The lead site (Children’s Mercy Kansas City) sent an email with an introduction and web-link to the survey to program directors at participating programs who then forwarded to their residents for completion. Two email reminders were sent to maximize survey response rate. No incentives were provided for the survey completion. We administered the survey using an encrypted electronic data capture system. Responses were anonymous.

 

Analysis. Results were analyzed categorically using SAS (v 9.4). The distributions of resident responses to specific items of interest were compared by reported year of training, with Fisher's exact test applied to determine statistical significance.

Results/Analysis

Population. The surveyed population included residents from 9 training institutions (1 FM program, 7 pediatric programs, and 1 program with both FM and pediatric residencies). These institutions were in six states (California, Indiana, Kansas, Missouri, Pennsylvania, Tennessee) and were of various size (range:19 to 108 residents per program). Over a 2-week allotted period, 126 residents (14% of all residents at participating institutions) completed the online survey. Respondent residents’ training levels varied [51 were post-graduate year (PGY1), 31 PGY2, 38 PGY3, 3 PGY4, and 3 unspecified]. Most respondents were female (69%) and aged 25-29 years (76%). Respondents identified their race/ethnicity as White (68%), Asian (20%), Hispanic (7%), or African American (2%).

 

Resident Confidence. (Figure 1) Almost all residents reported moderate or high familiarity with childhood immunizations. Regarding the statement “I am confident answering questions about vaccines”, 17.5% of residents strongly agreed, 58.7% somewhat agreed, 16.7% were neutral, and 6.3% somewhat disagreed. The proportion of residents strongly agreeing or agreeing to this question increased with each additional year of training (p<0.01).

 

Figure 1: Residents’ responses to question regarding confidence in answering all vaccine questions (“I am confident answering questions about vaccines”), by resident year

Resident Vaccine Attitudes and Hesitancy. All respondents considered vaccines to be an important part of children’s care. The proportion of residents rating individual vaccines as “highly important” varied by specific vaccine (e.g., >99% for MMR and Hib, but fewer for HPV (68%) or influenza (61%) vaccines). In response to the question “Overall, how hesitant about childhood vaccines would you consider yourself to be?”, 21% of respondents selected “somewhat hesitant” or “neutral”. In response to the question “How concerned are you that one or more of the recommended childhood vaccines may not be safe?”, 14% reported being “neutral”, “unsure” or “somewhat concerned” (Figure 2). The proportion of residents who reported not giving all recommended vaccinations for reasons other than illness or allergy (e.g., parent refusal) increased with each additional year of training (p<0.01).

Figure 2: Proportion of residents’ responses to two questions, “Overall, how hesitant about childhood vaccines would you consider yourself to be?” and “How concerned are you that one or more of the recommended childhood vaccines may not be safe?”.

Training Needs.  Residents reported that education on childhood vaccines was somewhat or very important for their future careers (99%), yet 56% reported not having, or not knowing if their residency program had a vaccine training curriculum. Most (88%) residents wanted to learn more about recommended childhood vaccines, most frequently citing a need to learn vaccine communication skills (80%) and vaccine benefits (65%) (Figure 3, responses not mutually exclusive). Vaccine safety, vaccine effectiveness, vaccine side effects, and risk of serious adverse events were also frequently selected as needed educational topics. Most preferred modalities for vaccine training included in-person lectures (66%), online modules (60%), and continuity clinic didactics (56%) (not mutually exclusive).

Figure 3: Resident respondents’ reported need to learn more about vaccine benefits, by resident year

Discussion

Our survey found that residents have high familiarity with vaccines and desire additional vaccine training. Although confidence in discussing vaccines increased with additional years of training, residents were more likely to skip recommended vaccines for non-medical reasons with increased years of training. Surprisingly, 21% of survey respondents were “somewhat hesitant” or “neutral” toward vaccines, and a substantial fraction value HPV and influenza less than other routinely recommended vaccines. Results from this survey support the need that standardized, evidence-based vaccine education in residency programs is needed to 1) clarify the important risks and benefits of vaccination, 2) equip residents with communication skills to address vaccine concerns, and 3) counter the vaccine hesitancy that may exist in the residents themselves.

 

Evidence supports that a strong provider recommendation for vaccines is one of the most powerful mechanisms to affect parents’ vaccination decision-making (Opel et al., 2012). Thus, identification of vaccine hesitancy among future healthcare providers who will be recommending vaccines for the community is concerning. It is critical that we adequately educate our future healthcare providers about the scientific evidence regarding the importance and safety of vaccines, and about how to counter any vaccine hesitancy, during the formative years of training.

 

A vaccine curriculum should also include topics that may be less understood by healthcare providers, such as the process for determining and ensuring vaccine safety and the impact vaccination has had on public health. For example, since a third of respondents do not believe influenza vaccine is very important, the curriculum could highlight that influenza is the leading cause of vaccine preventable death in children and one of the leading causes of vaccine preventable death in adults, resulting in more than 100 pediatric deaths and 12,000 to 56,000 adult deaths annually (Centers for Disease Control and Prevention, 2010; Centers for Disease Control and Prevention, 2017; Shang et al., 2018). Further, the curriculum could teach residents that half of recent pediatric influenza deaths occurred among previously healthy children, and these children were less likely to be vaccinated. Residents need an evidence-based vaccine curriculum that teaches providers the importance of all recommended vaccines and the burden of the vaccine preventable diseases.

 

Limitations of this study include that the respondents were recruited from a small number of residency programs using a convenience sample. The nine programs included two specialties and six states, but it is possible that volunteer programs had weaker than average immunization training. Similarly, the resident survey response rate was low, and it cannot be discerned if a biased sample responded (e.g., a high proportion of pro-vaccination residents).

Conclusion

This survey of pediatric and family medicine residents demonstrated a clear need for better vaccine education. A substantial proportion of residents self-reported vaccine hesitancy. Recognition of the importance of HPV and influenza vaccines was also often lacking. As future health care providers, it is critical for trainees to understand the importance and safety of all vaccines and to learn how to communicate with patients and families who have vaccine concerns.

Take Home Messages

  • Pediatric and Family Medicine residents want to learn more about vaccine benefits.
  • Some residents have concerns about the safety and/or necessity of vaccines (vaccine hesitancy).
  • Confidence in vaccine communications is related to year of training.

Notes On Contributors

Sarah Williams MD, MPH: Assistant Professor of Pediatrics in the Department of Pediatrics at Vanderbilt University Medical Center in Nashville, Tennesse. Her research focuses on pediatric immunization and medical education across the spectrum of lifelong learners.

Shannon Clark MPH: Program Director for CoVER in the Department of Pediatrics at Children's Mercy Hospital in Kansas City, Missouri.

Barbara Pahud MD, MPH: Associate Professor of Pediatric Infectious Disease in Department of Pediatrics at Children's Mercy Hospital in Kansas City, Missouri. She is a national leader in vaccine-related research.

Sharon Humiston MD, MPH: Professor of Pediatrics at Children’s Mercy Hospital in Kansas City with extensive expertise in immunization-related research and provider education.

Donald Middleton MD: Professor of Family Medicine at the University of Pittsburgh Medical Center. He has dedicated his career to advocating and teaching prevention medicine.

Kadriye O. Lewis Ed.D: Professor and Director of Evaluation and Program Development in the Department of Pediatrics at Children's Mercy Hospital in Kansas City, Missouri with extensive experience in developing, implementing, and evaluating education techniques and curricula for medical providers.

Acknowledgements

Funding for this work was provided through the Pfizer Foundation Independent Grants for Learning & Change. No copyright licenses are associated with the included figures as each was created de novo to represent this work. 

Bibliography/References

Centers for Disease Control and Prevention (2010) 'Estimates of deaths associated with seasonal influenza --- United States, 1976-2007', MMWR Morb Mortal Wkly Rep, 59(33), pp. 1057-62. http://www.ncbi.nlm.nih.gov/pubmed/20798667

 

Centers for Disease Control and Prevention (2017) Estimated Influenza Illnesses, Medical Visits, Hospitalizations, and Deaths Averted by Vaccination in the United States. Available at: https://www.cdc.gov/flu/about/disease/2015-16.htm (Accessed: 19/6/2018).

 

Glanz, J. M., McClure, D. L., Magid, D. J., Daley, M. F., et al. (2010) 'Parental refusal of varicella vaccination and the associated risk of varicella infection in children', Arch Pediatr Adolesc Med, 164(1), pp. 66-70. https://doi.org/10.1001/archpediatrics.2009.244

 

Glanz, J. M., McClure, D. L., Magid, D. J., Daley, M. F., et al. (2009) 'Parental refusal of pertussis vaccination is associated with an increased risk of pertussis infection in children', Pediatrics, 123(6), pp. 1446-51. https://doi.org/10.1542/peds.2008-2150

 

McCarthy, M. (2015) 'Measles outbreak linked to Disney theme parks reaches five states and Mexico', BMJ, 350, p. h436. https://doi.org/10.1136/bmj.h436

 

Opel, D. J., Robinson, J. D., Heritage, J., Korfiatis, C., et al. (2012) 'Characterizing providers' immunization communication practices during health supervision visits with vaccine-hesitant parents: a pilot study', Vaccine, 30(7), pp. 1269-75. https://doi.org/10.1016/j.vaccine.2011.12.129

 

Shang, M., Blanton, L., Brammer, L., Olsen, S. J., et al. (2018) 'Influenza-Associated Pediatric Deaths in the United States, 2010-2016', Pediatrics, 141(4). https://doi.org/10.1542/peds.2017-2918

 

Siddiqui, M., Salmon, D. A. and Omer, S. B. (2013) 'Epidemiology of vaccine hesitancy in the United States', Hum Vaccin Immunother, 9(12), pp. 2643-8. https://doi.org/10.4161/hv.27243

 

Williams, S. E. and Swan, R. (2014) 'Formal training in vaccine safety to address parental concerns not routinely conducted in U.S. pediatric residency programs', Vaccine, 32(26), pp. 3175-8. https://doi.org/10.1016/j.vaccine.2014.04.001

Appendices

None.

Declarations

There are some conflicts of interest:
All authors received funding from the Pfizer Foundation through an Independent Grant for Learning & Change, the following are additional conflict of interest disclosures:
KL - No additional conflicts
BP - Clinical investigator on trials funded by GlaxoSmithKline, Pfizer, and Alios Biopharma/Janssen and has received honoraria from Pfizer, Sequirus, and Sanofi Pasteur for service on advisory boards and nonbranded presentations.
DM - Advisory boards for Pfizer, GlaxoSmithKline, and Sanofi Pasteur, lectures for Pfizer and Seqirus, co-principal investigator for a CDC grant.
SW - Additional grant funding from the American Academy of Pediatrics and Pfizer for an Independent Grant for Learning & Change.
SH - Consultant to Immunization Action Coalition (nonprofit organization) and Sanofi Pasteur.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Ethics Statement

Approved through the Institutional Review Board of Children's Mercy Kansas City (IRB 16050332).

External Funding

All authors received funding from the Pfizer Foundation through an Independent Grant for Learning & Change (grant reference number 500704.0718.01).

Reviews

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Ken Masters - (21/05/2020) Panel Member Icon
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The paper deals with identifying medical residents’ perceived needs in vaccine education though a needs assessment survey. As the authors point out in their introduction, the issue of vaccination is fraught with debate and complexity, and not helped by a large amount of misinformation. (An added level of complexity, unfortunately, is the repeated news about unethical behaviour by pharmaceutical companies who are portrayed as placing concerns about profits before all else, and doctors (and now electronic medical systems) that collude in over-prescription; all of which serves to erode the public's faith in medical services, and leaves them easily open to suggestions that vaccines are merely a means to profit-making).

It is within this background that doctors have to face patients, carers and parents of patients who are sceptical and sometimes aggressively anti-vaccine.


One point:
• “Our survey found that residents have high familiarity with vaccines…” One should be careful about making this statement, as the survey ask an opinion, and does not measure residents’ actual knowledge. Asking people whether or not they know something is not a method to determine whether or not they actually do know it. (If it were, medical schools would not have examinations – we would simply ask students “How confident are you to be a cardiologist” and then grant a qualification to all who answered “very”). So, the most we can say is that the students have the opinion that…. And then the paper’s limitations need to stress that knowledge was not tested.

Given the limitations of the study, I would suggest that the authors (and readers) view this as an early exploratory study only. Although the survey is useful, as it shows a need for training in the area, it is a start only, and I would advise against designing an intervention based only on these results. Apart from the limitations mentioned by the authors, the survey is very narrow in its focus (as a first survey, that is fine), but there would need to be a more detailed study that would certainly have to involve qualitative data (from interviews and focus groups) to dig deeply into the issues so that intervention/s could be well-designed and delivered to meet the residents' needs.

In addition, given so many of the authors’ close association with pharmaceutical companies, I would strongly recommend that future papers on the topic include several authors with no such affiliations (and/or are independently reviewed), and that training intervention/s are mindful of this possible conflict of interests. Otherwise, even though the affiliations are openly declared, the accusation of bias will be difficult to counter.


Possible Conflict of Interest:

For transparency, I am an Associate Editor of MedEdPublish.

Shazia Iqbal - (16/03/2020)
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I thorough enjoyed reading this article as Topic and relevant to the time and modern medical education. It is imperative to add awareness strategies about vaccine making it part of curriculum. Abstract is clear with title and most of the references are relevant and well written. Important concern of curriculum development regarding the organized curriculum on vaccine safety or parental vaccine hesitancy is clearly mentioned by authors. Further research gaps has been identifying by explaining that “it is unknown whether residents harbor vaccine hesitant attitudes similar to the general population, which would undermine their vaccine recommendations”.
Methods of study are clear however it would have been significant to use the validated tool with up to-date references for validity of research questions in the questionnaire.
Results are presented with in organised form and they are meaningful. Results are mentioned very clearly, by mentioning that residents have high familiarity with vaccines and desire additional vaccine training.
Figures are very clear however title of figures is too long and need to be shortened.
Authors have highlighted that residents need an evidence-based vaccine curriculum which is very important aspect to be addressed by curriculum developers. Over all study is appropriate and the aim of study is achieved with valuable conclusion that it is important for trainees to understand the importance and safety of all vaccines and to learn how to communicate with patients and families who have vaccine concerns.
My Conclusion
Study is important for curriculum developer at undergraduate and post graduate level. Awareness is important for all sub specialities including obstetrics and gynaecology, surgeon, community a public health professionals etc. Although authors have examined the needs assessment survey to gauge/obtain paediatric and family medicine residents’ needs in vaccine education in the US, it would have been very helpful for the healthcare professionals to provide some model of enhancing the awareness. It could be in the form of some figure or acronym to enhance the vaccination education.
Leila Niemi-Murola - (15/03/2020) Panel Member Icon
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Thank you for the opportunity to review this interesting article about residents’ perceived needs in vaccine education. This topic is unexpectedly hot now, in the middle of the COVID-19 pandemic, potentially lethal because there is no vaccine available so far. However, before the eruption of this pandemic, there were increasing resistance to vaccination in many countries, the parents of young children clearly not understanding the risks of infection and the benefits of vaccination.
The authors have delivered a questionnaire with 22 items to 126 US pediatric and family medicine residents working in several states. They don’t give any motivation, why did they wish to conduct this study in the first place – had there been problems with increasing parents’ resistance? An international reader would like to know more about their previous studies, how much they were expected to know about sero-bacteriology and virology? The authors do not report the method of the statistic analysis, nor the validity or the reliability of the instrument. Were there any differences between the residents working in different states?
It is easy to agree with the conclusion, there is clearly need for more and intensified education about the benefits of vaccination. The residents need information to convince the hesitating parents of their young patients.
Felix Silwimba - (15/03/2020)
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I find this study relevant everywhere, even though vaccines are seen as routine activities in most low income countries and tied to donor support. the extent to which the health workers know about vaccines and their own views is not known. I recommend such a study to all regions.