Structural and relational factors for successful cross-sector collaboration in home visiting: a multiple case study.

BACKGROUND: Aligning delivery and financing systems across sectors to create broader systems of care can improve the health and well-being of families experiencing adversities. We aimed to identify structural and relational factors for best practices to achieve successful cross-sector collaboration among home visiting programs in the United States. MATERIALS AND METHODS: We used a multiple case study approach to identify best practices for successful cross-sector collaboration between home visitors and other community service providers. We selected five diverse exemplary cases with cross-sector collaboration with variation in implementing agency type and geographic location. Cases were selected using a positive deviance approach based on strong coordination and integration with different community service provider types identified from previous survey data. We conducted in-depth qualitative interviews with home visiting staff, community providers, and clients with a total of 76 interviews conducted from 2021 to 2022. We wrote memos to synthesize themes within each case through data triangulation using interview data, documents, and site visit observations. We compared themes across the five cases to create a cross-case synthesis of best practices for successful cross-sector collaboration. RESULTS: Across the five cases, relational factors including leadership from all levels, champions across sectors, and shared goals between community providers were key factors for successful collaboration. Interpersonal relationships, coupled with the desire and capacity to engage, facilitated effective coordination to address families' needs. At the structural level, shared data systems, written agreements, and co-location enabled care coordination activities. Community Advisory Boards provided a venue for developing partnerships, relationship-building, resource-sharing, and increasing awareness of home visiting. CONCLUSIONS: We identified key elements of successful cross-sector collaboration across five case studies where home visitors coordinate care frequently and/or are structurally integrated with a range of providers. These learnings will inform future interventions to improve home visiting collaboration with other community providers to create a system of care to enhance family well-being.

Coordination of family's care in an evidence-based nurse home visiting program.

Interprofessional care coordination within evidence-based prevention programs like Nurse-Family Partnership® (NFP) is necessary to meet family needs and maximize program impact. This study aimed to describe the coordination of families' care in the NFP home visiting context. We used an adapted grounded theory approach and purposively sampled seven NFP sites. We conducted telephone interviews with 95 participants: 51 NFP staff (54%), 39 healthcare providers (41%), and 5 social service providers (5%). All interviews were recorded, transcribed, validated, and analyzed in NVivo11. Many community providers in all sites described their knowledge of the characteristics of the NFP intervention, including the strength of its evidence to achieve outcomes. Care coordination was dynamic and changed over time based on client needs and staff willingness to work together. Effective care coordination in the NFP context from the provider perspective is driven by shared knowledge, integrated systems, mission alignment, and individual champions who value the program.

Changes in cross-sector collaboration between nurse home visitors and community providers in the United States: A panel survey analysis.

OBJECTIVE: Assess changes in cross-sector collaboration between Nurse-Family Partnership (NFP) nurse home visitors and community providers in the United States. DATA SOURCES AND STUDY SETTING: We collected primary data via internet-based surveys of all NFP nursing supervisors in the United States in 2018, 2020, and 2021. STUDY DESIGN: We conducted a panel survey to measure changes in cross-sector collaboration between NFP nurses and 10 provider types in healthcare and social services. We assessed relational coordination using the validated seven item Relational Coordination Scale and structural integration using four items adapted from the Interagency Collaboration Activities Scale. Responses over time were compared using one-way analysis of variances (ANOVAs) and pairwise t-tests. We used the Kruskal-Wallis rank test to assess differences in collaboration by implementing agency type. DATA COLLECTION: All nursing supervisors from NFP implementing agencies in the United States were eligible for the study. Survey implementation was conducted using Qualtrics and administered to all eligible participants (N = 370 [2018], 383 [2020], 414 [2021]). Email reminders were sent every 7-10 days, followed by a final telephone outreach. PRINCIPAL FINDINGS: The response rate was 71% in 2018, 83% in 2020, and 74% in 2021. Relational coordination scores were calculated as a mean of the seven items and ranged from 1 to 5 (not at all to completely); integration scores were calculated as a sum of the four items and ranged from 4 to 20, where higher scores indicated greater sharing of resources. Coordination with women's care increased from 2018 to 2020 (M = 3.39 vs. 3.57; p < 0.01); while coordination (M = 3.23 vs. 3.01; p < 0.05) and integration (M = 6.50 vs. 5.28 vs. 5.43; p < 0.01) with parenting programs decreased. CONCLUSIONS: Changes to cross-sector collaboration varied by provider type, likely due to the delivery of NFP and other services via telehealth during the COVID-19 pandemic. There is an opportunity to improve cross-sector collaboration in home visiting to better address family needs.

Engaging Community in Prioritizing Outcomes to Improve Family Health in Evidence-Based Nurse Home Visiting: Using a Modified e-Delphi Method.

BACKGROUND: Evidence-based home visiting programs are designed to improve maternal child health. Nurse-Family Partnership (NFP) is a model evidence-based home visiting program, shown to improve pregnancy outcomes, child development, and economic self-sufficiency for first-time mothers and their families experiencing social and economic adversities, enrolling them early in pregnancy. Recently, NFP has expanded its services to multiparous women (previous live births) and enrolling women past 28 weeks gestation (late registrants) in selected agencies in Florida since 2021. OBJECTIVE: To study the process and impacts of expanding NFP to expanded populations (multiparous and/or late registrants), we convened a diverse Advisory Committee to guide the NFP expansion evaluation in Florida. METHODS: This study employed a modified e-Delphi method with three rounds of data collection, to engage diverse partners to identify process and impact outcomes for the NFP expansion evaluation. RESULTS: Child maltreatment was identified as the highest priority outcome. Process outcomes included program reach, client enrollment, and client engagement, while impact outcomes included maternal physical health, maternal mental health and substance use, birth outcomes, and breastfeeding practices. The Advisory Committee further identified potential data sources to measure these outcomes. CONCLUSIONS FOR PRACTICE: Identifying and selecting key process and impact outcomes using a community-engaged process is necessary to ensure equal buy-in from all partners and to inform rigorous program evaluation. This study showed that using methods such as e-Delphi is feasible and effective for achieving thoughtful and rigorous decision-making, even in times of uncertainty like the COVID-19 pandemic.

Socioemotional Development of Infants and Toddlers During the COVID-19 Pandemic.

Importance: Understanding the impact of the COVID-19 pandemic on children's socioemotional development is critical to plan for ongoing needs in the early intervention and education systems. Objective: To determine if Ages and Stages Questionnaire, Third Edition (ASQ-3) and Ages and Stages Questionnaire Social-Emotional, Second Edition (ASQ:SE-2) scores changed during the COVID-19 pandemic among families served by a nurse-visiting program. Design, Setting, and Participants: This retrospective, cohort study took place from 2015 through 2021 and included 4 cohorts (prepandemic, pandemic 1, pandemic 2, and pandemic 3) with differing pandemic exposure at the time of screening. Analysis was conducted from July 2022 through October 2023. Data from the Nurse-Family Partnership (NFP), a national nurse-visiting program enrolling birthing people during pregnancy and continuing through age 2 years, were used. A total of 60 171 families with a singleton birth at 37 weeks' gestation or longer and at least 1 valid ASQ-3 and/or ASQ:SE-2 screening in the NFP from January 1, 2015, through December 31, 2021, were enrolled. Exposure: COVID-19 pandemic. Main Outcomes and Measures: Outcomes were a positive screening, defined as scores in the refer area on the ASQ-3 at 10 months and 18 months of age and in the ASQ:SE-2 at 12 months and 18 months of age. Multivariable mixed-effects logistic regression models were used to calculate odds ratios (ORs) for positive screening in pandemic cohorts compared with the prepandemic cohort. Covariates included parent age, race and ethnicity, marital status, income, child's biological sex, and multiparity. Results: Of 60 171 families enrolled, pandemic cohorts had fewer teenagers, were more likely to be married, and were multiparous. Compared with the prepandemic cohort, all pandemic cohorts had higher odds of positive screening on the ASQ-SE at 12 months (pandemic 1: OR, 1.35; 95% CI, 1.09-1.66; pandemic 2: OR, 1.60; 95% CI, 1.30-1.96; and pandemic 3: OR, 1.94; 95% CI, 1.61-2.33) and pandemic 2 and 3 had higher odds of a positive screening at 18 months (pandemic 2: OR, 1.61; 95% CI, 1.29-2.00 and pandemic 3: OR, 1.87; 95% CI, 1.50-2.32). On the ASQ-3, pandemic cohorts 2 and 3 were more likely than the prepandemic cohort to screen positive on the communication subscale at 18 months (pandemic 2: OR, 1.39; 95% CI, 1.17-1.64 and pandemic 3: OR, 1.28; 95% CI, 1.07-1.53). Conclusions and Relevance: In this study, exposure to the COVID-19 pandemic, especially during the first year of life, was associated with higher odds of positive ASQ:SE-2 screening, even when adjusting for demographics and family risks. These findings suggest that unmeasured community, family, and child factors that changed as a result of the pandemic contributed to delays in young children's socio-emotional development.

Corporal Punishment in Schools.

The use of corporal punishment in schools is not an effective or ethical method for management of behavior concerns and causes harm to students. The American Academy of Pediatrics recommends that corporal punishment in all school settings be abolished in all states by law and replaced by alternative forms of student behavior management. Corporal punishment remains legal in many public and private schools in the United States and is disproportionately used among Black students and children with disabilities. The aims of this policy statement are to review the incidence of school-based corporal punishment; the negative physical, psychological, and developmental impact of corporal punishment on students; and the need for continued advocacy by pediatricians, educators, and parents to abolish corporal punishment in all schools.

Finger Puppets to Support Early Language Development: Effects of a Primary Care-Based Intervention in Infancy.

Verbally rich interactions beginning in early infancy are critical to future vocabulary development. We explored the effectiveness of introducing finger puppets in the primary care setting to support caregiver-infant interactions. The intervention cohort was given a puppet at 2 months, with high dosage defined as using the puppet daily in the first 2 weeks. At 6 months, a usual care cohort was enrolled, and outcome measures were collected for all participants. For the intervention, 92% (n = 70) of those eligible participated, and 80% (n = 56) completed the 6-month visit. For usual care, 78% (n = 60) of those eligible participated. In per-protocol analysis, overall cognitive stimulation (StimQ-I) (P = .04) and Parental Involvement in Developmental Advance subscale (P = .03) scores were higher for the high-dosage group (28.68, 5.16) than those for the low-dosage (24.81, 4.48) and usual care (24.15, 3.98) groups. Finger puppets may provide a low-cost and scalable way to support early language and child development.

Engage, Develop, Learn: a pilot randomized clinical trial to test if a mobile application can enhance home support for early cognitive development among children living in poverty.

Background: Mobile applications (apps) exist to promote early child development; however, few studies have examined use of these apps among low-income families. Our objectives were to measure engagement with the Engage, Develop, Learn (EDL) app and determine if it promoted engagement and behavior change among low-income caregivers. Methods: We conducted a pilot study among English and Spanish-speaking, low-income families with children ages 12 to 15 months who received either the EDL app or injury prevention text messages. Baseline data were collected and interventions delivered over two home visits. App engagement was measured using messages opened. Caregiver development-promoting behaviors were measured with STIMQ score changes from baseline to follow-up at child age 2 years. We conducted key informant interviews among families randomized to receive the EDL app to identify barriers and facilitators to app use. Results: A total of 100 caregivers were recruited at their children's preventive care visit with 50 randomized to receive the EDL app and 50 to receive the injury prevention text messages; however, only 25 in the development app and 34 in the injury prevention group completed both home visits. Follow-up data were collected from 14 in the development app group and 30 in the injury prevention group. Over 10 weeks, 24% (6/25) remained engaged with the development app. STIMQ scores did not differ between groups. Barriers included technical difficulties accessing the app, social stressors, and 'forgetting' to use it. Conclusions: Our pilot randomized trial of a child development app suggests that it may not be effective for promoting behavior change among low-income caregivers due to low engagement. Trial Registration: This pilot trial was registered with ClinicalTrials.gov (ID NCT02717390).

A qualitative study of effective collaboration among nurse home visitors, healthcare providers and community support services in the United States.

Collaboration across sectors is needed to improve community health, but little is known about collaborative activities among public health prevention programs. Using the Nurse-Family Partnership® (NFP) home visiting program as context, this qualitative study aimed to describe effective collaboration among nurse home visitors, healthcare providers and community support services to serve families experiencing social and economic adversities. We used grounded theory to characterise collaboration with six purposively sampled NFP sites in the United States through in-depth interviews. We interviewed 73 participants between 2017 and 2019: 50 NFP staff, 18 healthcare providers and 5 other service providers. Interviews were recorded, transcribed, validated and analysed in NVivo 11. Validation steps included inter-coder consistency checks and expert review. Thematic memos were synthesised across sites. Most participants perceived collaboration to be important when serving families with complex needs, but substantial variation existed in the degree to which NFP nurses collaborate with providers dependent on provider type and community context. Factors that contributed to effective collaboration were relational in nature, including leadership commitment and provider champions, shared perceptions of trust, respect and value, and referral partnerships and outreach; organisational in terms of mission congruence between providers; and structural such as policy and system integration that facilitated data sharing and communication channels. These findings provide greater insights into effective cross-sector collaboration and care coordination for families experiencing adversities. Collaboration across sectors to promote health among families experiencing adversities requires intentional efforts by all inter-professional providers and continued commitment among all levels of leadership to coordinate services.

A case study of care co-ordination between primary care providers and nurse home visitors to serve young families experiencing adversity in the Northwestern United States.

Nurse home visitors in Nurse-Family Partnership® (NFP) work with mothers experiencing social and economic adversities to improve their and their children's health. Collaboration between nurse home visitors and primary care providers (PCPs: healthcare providers and social workers embedded within obstetrics, paediatrics and family medicine practices) can improve service delivery for families experiencing the greatest adversities. However, little is known about how and to what extent PCPs collaborate with home visiting nurses. We conducted a single exploratory case study between April 2019 and February 2020 to better understand how PCPs collaborate with home visiting nurses to meet family needs in one NFP site, purposefully selected for strong collaboration. We conducted in-depth qualitative interviews with 22 PCPs, including 5 nurses, 7 physicians, 7 social workers and 3 non-direct care professionals, including patient navigator and hospital executives. Interviews were recorded, transcribed, validated and coded inductively. Codes were grouped into broader categories and thematic memos across provider role were written to triangulate perspectives. Healthcare providers interacted with home visiting nurses mainly during the referral process, while social workers provided more specific examples of service co-ordination. In this case study, we saw mutual awareness, co-operation and collaboration to serve families with high needs. Even in this case, purposefully selected to represent strong collaboration, there were opportunities to enhance co-ordination to improve the health and social needs of young families experiencing adversity.

A Qualitative Study of Mothers' Perspectives on Enrolling and Engaging in an Evidence-Based Nurse Home Visiting Program.

Prevention programs like Nurse-Family Partnership® (NFP) must enroll and retain clients of the intended population to maximize program impact. NFP is an evidence-based nurse home visitation program shown in randomized trials to improve maternal and child health and life course outcomes for first-time parents experiencing economic adversity, particularly for mothers with limited psychological resources. The purpose of this study was to understand enrollment and engagement experiences of mothers with previous live births referred to NFP in a formative study of the program for this population, but did not enroll or dropped out before program graduation. We used a grounded theory approach and purposively selected three NFP sites with variation in enrollment rates. We conducted telephone interviews with 23 mothers who were either referred to NFP and declined enrollment or former clients who dropped out before graduation. All interviews were conducted in English, recorded, transcribed, and validated. We developed an iterative codebook with multiple coders to analyze our data in NVivo11 and wrote thematic memos to synthesize data across study sites. Mothers described experiencing overlapping risk factors including physical and behavioral health conditions, child welfare involvement, and housing insecurity. Mothers from all sites discussed how they were referred to the NFP program, their experience of the enrollment process, reasons for enrolling or not enrolling, and reasons for dropping out after initial enrollment. Key themes that influenced mothers' decision-making were: perceptions of program value, not needing the program, their living situation or being too busy as a deterrence, and past experiences including a distrust of health care. Reasons for attrition were related to no longer needing the service, being assigned a new nurse, being too tired postpartum, and moving out of the service area. One way to support home visiting nurses in family enrollment and engagement is to build their professional capacity to implement trauma-informed strategies given mothers' life experiences.

Pediatric Group Care: A Systematic Review.

OBJECTIVE: To describe characteristics and outcomes of Group Well-Child Care programs and provide recommendations for future research. METHODS: Informed by Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, an electronic references database, manual search of bibliographies and peer-reviewed journals, and general Internet search were conducted including research published up to July 2019. English language, peer-reviewed research, with provision of medical care were included. Studies without published outcomes, not specific to well-child care, or included only one visit were excluded. Nineteen articles met review criteria. Study quality was assessed using the Downs and Black tool for rigor. RESULTS: Programs typically included an individual medical examination, check-in, and group discussion. Demographics varied by race, ethnicity, age, income level, education and parity, though many were used specifically with underserved populations. Group size ranged from 3 to 10 and lasted an average of 1.5 h over a period of 6-24 months. Evidence suggests group well-child care is as effective as individual care with improvement noted for health-care utilization, weight outcomes, and more content covered. Design elements such as patient-led discussion, self-check-in, inclusion of other family members, and use of a variety of health care professionals and para-professionals may influence these outcomes. CONCLUSIONS: Group well-child care is useful in providing efficient and patient-centered care and shows promise for use in underserved populations. Future research should utilize more rigorous study design and include evaluations of program components and group processes to address implementation challenges and determine effectiveness.

Changes in Strength of Recommendation and Perceived Barriers to Human Papillomavirus Vaccination: Longitudinal Analysis of Primary Care Physicians, 2008-2018.

OBJECTIVES: To evaluate among pediatricians and family physicians human papillomavirus (HPV) vaccination recommendation practices for 11- to 12-year-old youth; report parental refusal/deferral of HPV vaccination; and report barriers to HPV vaccination changed over time. STUDY DESIGN: We surveyed nationally representative networks of pediatricians and family physicians in 2008, 2010, 2013-2014, and 2018. Male vaccination questions were not asked in 2008; barriers and parental vaccine refusal questions were not asked in 2010. RESULTS: Response rates were 80% in 2008 (680/848), 72% in 2010 (609/842), 70% in 2013-2014 (582/829), and 65% in 2018 (588/908). The proportion of physicians strongly recommending HPV vaccination for 11- to 12-year-old patients increased from 53% in 2008 to 79% in 2018 for female patients and from 48% in 2014 to 76% in 2018 for male patients (both P < .0001). The proportion of physicians indicating ≥50% of parents refused/deferred HPV vaccination remained steady for female patients (24% in 2008 vs 22% in 2018, P = .40) and decreased for male patients (42% in 2014 vs 28% in 2018, P < .001). Physician barriers to providing HPV vaccination were rare and decreased over time. Increasing numbers of physicians reported perceived parental barriers of vaccine safety concerns (5% "major barrier" in 2008 vs 35% in 2018, P < .0001) and moral/religious concerns (5% in 2008 vs 25% in 2018, P < .0001). CONCLUSIONS: Between 2008 and 2018, more primary care physicians reported recommending HPV vaccination for adolescents, fewer reported barriers, and more physicians reported parents who had vaccine safety or moral/religious concerns.

Transmission of Intergenerational Parenting Attitudes and Natural Mentorship: Associations Within the LONGSCAN population.

BACKGROUND: Evidence suggests that families transmit child maltreatment and parenting attitudes. Natural mentorship may mediate intergenerational parenting attitudes' risk for maltreatment but has not been studied. OBJECTIVE: To compare parenting attitudes between adolescents exposed to or at risk for maltreatment and their caregivers and to determine if natural mentorship mediates differences in parenting attitudes' maltreatment risk. PARTICIPANTS AND SETTING: The study included 779 children and their caregivers from the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) study, METHODS: Standardized measures assessed parenting attitudes, natural mentorship and demographic characteristics. Repeated measures, multivariable logistic regressions were used to predict low risk parenting attitudes for maltreatment among adolescents with and without natural mentors. RESULTS: In adjusted analysis, natural mentorship did not predict an adolescent having low risk parenting attitudes when their caregivers had moderate or high risk attitudes: appropriate empathy adjusted odds ratio [aOR] = 1.26; 95% confidence interval [CI] 0.52 -3.01; appropriate expectations aOR = 1.35; CI 0.62-2.93; physical punishment rejection aOR = 1.74; CI 0.78-3.88; and appropriate roles aOR = 1.11; CI 0.57-2.18. Low risk caregiver parenting attitudes for appropriate empathy related to adolescents having low risk empathy attitudes (aOR = 2.89; CI 1.31-6.37). Male gender, African American race and Hispanic ethnicity were negatively associated with an adolescent having low risk parenting attitudes for maltreatment. CONCLUSIONS: Natural mentorship did not mediate adolescent parenting attitudes. While prevention and intervention strategies should include natural mentoring given positive health impacts, services must be cognizant of and designed for gender, racial and ethnic diversity.

Use of Standing Orders for Vaccination Among Pediatricians.

OBJECTIVES: Standing orders are an effective way to increase vaccination rates, yet little is known about how pediatricians use this strategy for childhood immunizations. We assessed current use of, barriers to using, and factors associated with use of standing orders for vaccination among pediatricians. METHODS: Internet and mail survey from June 2017 to September 2017 among a nationally representative sample of pediatricians. In the principal component analysis of barrier items, we identified 2 factors: physician responsibility and concerns about office processes. A multivariable analysis that included barrier scales and physician and/or practice characteristics was used to identify factors associated with use of standing orders. RESULTS: The response rate was 79% (372 of 471); 59% of respondents reported using standing orders. The most commonly identified barriers among nonusers were concern that patients may mistakenly receive the wrong vaccine (68%), concern that patients prefer to speak with the physician about a vaccine before receiving it (62%), and belief that it is important for the physician to be the person who recommends a vaccine to patients (57%). These 3 items also made up the physician responsibility barrier factor. Respondents with higher physician responsibility scores were less likely to use standing orders (risk ratio: 0.59 [95% confidence interval: 0.53-0.66] per point increase). System-level decision-making about vaccines, suburban or rural location, and lower concerns about office processes scores were each associated with use of standing orders in the bivariate, but not the multivariable, analysis. CONCLUSIONS: Among pediatricians, use of standing orders for vaccination is far from universal. Interventions to increase use of standing orders should address physicians' attitudinal barriers as well as organizational factors.

Physicians' Use of Evidence-Based Strategies to Increase Adult Vaccination Uptake.

INTRODUCTION: This study assesses the following among primary care physicians: (1) the use of evidence-based strategies to improve adult vaccination rates, (2) the number of strategies employed simultaneously, and (3) characteristics associated with assessing adult vaccinations at each visit. METHODS: An internet and mail survey was administered between December 2015 and January 2016 on primary care physicians designed to be representative of the American College of Physicians and American Academy of Family Physicians memberships. Data analysis was conducted in 2019. RESULTS: The response rate was 66% (617 of 935); 94% reported using electronic health records. Standing orders (84%) and electronic provider reminders at a visit (61%) were the most common strategies reported for influenza vaccine. Electronic provider reminders at a visit (53%) and recording a vaccination in an immunization registry (32%) were the most common strategies reported for all noninfluenza vaccines. Most physicians reported using 2 or more strategies, although this was more common for influenza (74%) than for noninfluenza (62%) vaccines. In multivariable analysis, physicians who reported assessing adult vaccinations at every patient visit were more likely to work in practices where decisions about purchasing and handling vaccines were made at a larger system level (RR=1.20, 95% CI=1.04,1.40), and they reported using electronic provider reminders (RR=1.38, 95% CI=1.15, 1.69) and standing orders (RR=1.45, 95% CI=1.21, 1.75) for all noninfluenza adult vaccines. CONCLUSIONS: Several strategies are being used to increase adult vaccination, particularly for the influenza vaccine. Investment in implementing standing orders and electronic clinical decision support for all routine adult vaccinations could help facilitate assessment of adult vaccinations at each visit and potentially improve adult vaccination rates.

Pediatricians' Experiences With and Perceptions of the Vaccines for Children Program.

BACKGROUND AND OBJECTIVES: The Vaccines for Children Program (VFC) provides vaccines for children who may not otherwise be vaccinated because of financial barriers. Pediatrician participation is crucial to the VFC's ongoing success. Our objectives were to assess, among a national sample of pediatricians, (1) VFC program participation, (2) perceived burden versus benefit of participation, and (3) knowledge and perception of a time-limited increased payment for VFC vaccine administration under the Patient Protection and Affordable Care Act. METHODS: An electronic and mail survey was conducted from June 2017 to September 2017. RESULTS: Response rate was 79% (372 of 471); 86% of pediatricians reported currently participating in the VFC; among those, 85% reported never having considered stopping, 10% considered it but not seriously, and 5% seriously considered it. Among those who had considered no longer participating (n = 47), the most commonly reported reasons included difficulty meeting VFC record-keeping requirements (74%), concern about action by the VFC for noncompliance (61%), and unpredictable VFC vaccine supplies (59%). Participating pediatricians rated, on a scale from -5 (high burden) to +5 (high benefit), their overall perception of the VFC: 63% reported +4 or +5, 23% reported +1 to +3, 5% reported 0, and 9% reported -1 to -5. Of pediatricians, 39% reported awareness of temporary increased payment for VFC vaccine administration. Among those, 10% reported that their practice increased the proportion of Medicaid and/or VFC-eligible patients served on the basis of this change. CONCLUSIONS: For most pediatricians, perceived benefits of VFC participation far outweigh perceived burdens. To ensure the program's ongoing success, it will be important to monitor factors influencing provider participation.

Ten years of experience with herpes zoster vaccine in primary care- how attitudes and practices have changed and what it may mean for a new zoster vaccine.

Zoster vaccine live (ZVL [Zostavax]) has been recommended for the prevention of herpes zoster (HZ) among immunocompetent adults ≥60 years in the United States since 2008. To examine changes in healthcare providers' perceptions and practices related to HZ disease and vaccination, we administered surveys to national networks of primary care physicians in 2005, 2008, and 2016. Ten years after ZVL was first licensed, physicians were more likely to respond that they perceived HZ as a serious disease and more strongly recommended ZVL, and were less likely to report less likely to report several major barriers to HZ vaccination such as patient cost, vaccine effectiveness and competing medical concerns. Overall, physician attitudes appear to be more favorable towards zoster vaccination after a decade of availability of a HZ vaccine. The new recombinant zoster vaccine (RZV [Shingrix]) may benefit from physician's increased perception of the importance of HZ and HZ vaccination.

Survey of Adult Influenza Vaccination Practices and Perspectives Among US Primary Care Providers (2016-2017 Influenza Season).

BACKGROUND: Seasonal influenza vaccination is recommended for all adults; however, little is known about how primary care physicians can communicate effectively with patients about influenza vaccination. OBJECTIVE: To assess among general internal medicine (GIM) and family physicians (FP) regarding adult influenza vaccination: (1) recommendation and administration practices, (2) barriers to discussing and perceived reasons for patient refusal, and (3) factors associated with physician self-efficacy in convincing patients to be vaccinated. DESIGN: Email and mail survey conducted in February-March 2017 PARTICIPANTS: Nationally representative sample of GIM and FP MAIN MEASURES: Factor analysis was used to group similar items for multivariable analysis of barriers and strategies associated with high physician self-efficacy about convincing patients to be vaccinated (defined as disagreeing that they could do nothing to change resistant patients' minds). KEY RESULTS: Response rate was 67% (620/930). Ninety-eight percent always/almost always recommended influenza vaccine to adults ≥ 65 years, 90% for adults 50-64 years, and 75% for adults 19-49 years. Standing orders (76%) and electronic alerts (64%) were the most commonly used practice-based immunization strategies. Frequently reported barriers to discussing vaccination were other health issues taking precedence (41%), time (29%), and feeling they were unlikely to change patients' minds (24%). Fifty-eight percent of physicians reported high self-efficacy about convincing patients to be vaccinated; these providers reported fewer patient belief barriers contributing to vaccine refusal (RR = 0.93 per item; 95% CI (0.89-0.98); Cronbach's α = 0.70), were more likely to report using both fact- (1.08/item; (1.03-1.14); 0.66) and personal experience-based (1.07/item; (1.003-1.15); 0.65) communication strategies, and were more likely to work in practices using patient reminders for influenza vaccine (1.32; (1.16-1.50)). CONCLUSIONS: Physicians identified barriers to successfully communicating about adult influenza vaccination but few effective strategies to counter them. Interventions to promote self-efficacy in communication and under-utilized practice-based immunization strategies are needed.