HUMAN VACCINES & IMMUNOTHERAPEUTICS 2016, VOL. 12, NO. 5, 1293–1294 http://dx.doi.org/10.1080/21645515.2015.1127487
COMMENTARY
Assessing barriers to immunization Victoria Niederhausera and Catherine Ferrisb a College of Nursing, University of Tennessee Knoxville, Knoxville, TN, USA; bHahn School of Nursing and Health Science, University of San Diego, San Diego, CA, USA
ABSTRACT
ARTICLE HISTORY
Parental barriers to childhood immunizations vary among countries, states and communities. There is a plethora of studies that exist to examine barriers to immunizations including many intervention studies designed to improve immunization rates in children. Often, intervention studies designed to minimize barriers and increase immunization uptake among children lack the inclusion of a standardized instrument to measure accurately parental barriers to childhood immunizations before and after interventions. The Searching for Hardships and Obstacles To Shots (SHOTS) survey is a standardized survey instrument to measure parental barriers to childhood immunizations. In several studies, the SHOTS survey has demonstrated consistent reliability and has been validated in diverse populations. The inclusion of the SHOTS survey instrument in studies to examine barriers to childhood immunization will provide researchers and clinicians with a better understanding of parents’ individualized barriers to immunizations. Furthermore, use of the SHOTS survey instrument to collect information about parental barriers to immunizations can lead to targeted interventions to minimize these obstacles at the individual and community level and to help us to achieve our national, state and community childhood immunization goals.
Received 13 November 2015 Accepted 26 November 2015
Healthy People 2020 goals challenge achievement of 80% of children to be immunized by age 3 in the United States.1 As researchers and clinicians, we know that different barriers exist in different communities and with different populations. Furthermore, even within communities’ immunization rate disparities exist. There is a plethora of studies examining barriers to immunizations and many intervention studies to determine the best approaches to increasing immunization rates in children. Often these intervention studies are designed to improve immunization rates without inclusion of an instrument to assess if, and what barriers, existed before the intervention, and if those barriers were reduced through the intervention. Imagine that a researcher is awarded a large grant to conduct an intervention that is aimed at minimizing parental barriers to childhood immunizations. The randomized-controlled study was designed with one outcome variable, immunization rates differences before and after the intervention. After 2–3 years of much time invested and many dollars spent, the study is complete and the researchers anxiously analyze the data. The findings are clear; there are no significant differences in immunization rates between the intervention and control groups. The researcher is left speculating about the possibility that other variables should have been considered in the study design. When designing intervention studies to examine barriers to childhood immunizations, in addition to immunization rates as the outcome variable, researchers should consider assessing barriers before and after interventions. The Searching for Hardships and Obstacles To Shots (SHOTS) survey is one example CONTACT Victoria Niederhauser © 2016 Taylor & Francis
[email protected]
KEYWORDS
childhood immunizations; instrument; intervention; parental barriers to vaccines; vaccines
of a valid and reliable instrument used in studies to understand what is interfering with optimal immunization rates in populations.2 This short (23 items) and easy to understand (4th grade reading level) survey has been reliable and validated in studies.2-5 Additionally, the SHOTS survey has been used successfully with different populations including Asian-pacific Islanders and Native Alaskans and in community, research, rural, and primary care settings. The SHOTS survey assesses three common parental barriers to immunizations including access to immunizations, concerns about immunizations and importance of immunizations. Each of the 23 items is rated on a 5-point scale indicating how much it is a problem for the parent, with the lowest score a 0 (meaning the item is not a problem at all) to a 4 (indicating this item is a very big problem). It takes about 10 minutes for parents to complete the survey. The 23 items are grouped into the 3 subscales for analysis. A total barrier to immunization score is also calculated; the higher the score, the higher the parental barriers to getting their child’s immunizations. Adding the SHOTS survey or another standardized instrument that assesses parental barriers to childhood immunizations to intervention studies can enrich study designs and provide more detailed information about which barriers were present prior to an intervention and those barriers that were reduced by an intervention. We believe that this information will add to the scientific understanding of the complex parental barriers to childhood immunizations that exist and how we can target specific barriers with innovative interventions. The hope is that
College of Nursing, University of Tennessee Knoxville, 1200 Volunteer Blvd, Knoxville, TN 37996, USA.
1294
V. NIEDERHAUSER AND C. FERRIS
armed with a greater understanding for those things that interfere with parents getting their child shots, we can ultimately create targeted interventions based on specific individual barriers and achieve our Healthy People 2020 goal and beyond. For more information or to obtain permission to use the SHOTS survey, go to www.shotssurvey.org.
[2]
[3]
Disclosure of potential conflicts of interest No potential conflicts of interest were disclosed.
References [1] US. Department of Health and Human Services (USDHHS). Healthy People. Clinical Preventive Services Leading Health Indicators, Immu-
[4]
[5]
nizations and Infectious Disease. Accessed on October 15, 2020; 2015 at http://www.healthypeople.gov/2020/topics-objectives/topic/immuni zation-and-infectious-diseases/objectives Niederhauser V. Measuring parental barriers to childhood immunizations: The development and validation of the searching for hardships and obstacles to shots (SHOTS) instrument. J Nurs Meas 2010; 18:2635; PMID:20486475; http://dx.doi.org/10.1891/1061-3749.18.1.26 Baker D, Dang M, Ly MY, Diaz R. Perception of barriers to immunization among parents of Hmong origin. Am J Public Health 2010; 100:839-45; PMID:20299651; http://dx.doi.org/ 10.2105/AJPH.2009.175935 Baker D, Melnikow Ly, MK J, Shoultz J, Niederhauser V, Diaz-Escamilla R. Translation of health surveys using mixed methods. J Nurs Scholarsh 2010; 42:430-8; PMID:21091626; http://dx.doi.org/10.1111/ j.1547-5069.2010.01368.x Baker D. Parental perceptions of barriers to immunizations among the Hmong community in Central California. ProQuest Dissertations & Theses Global 2009; 3400898
COMMENTARY
Assessing barriers to immunization Victoria Niederhausera and Catherine Ferrisb a College of Nursing, University of Tennessee Knoxville, Knoxville, TN, USA; bHahn School of Nursing and Health Science, University of San Diego, San Diego, CA, USA
ABSTRACT
ARTICLE HISTORY
Parental barriers to childhood immunizations vary among countries, states and communities. There is a plethora of studies that exist to examine barriers to immunizations including many intervention studies designed to improve immunization rates in children. Often, intervention studies designed to minimize barriers and increase immunization uptake among children lack the inclusion of a standardized instrument to measure accurately parental barriers to childhood immunizations before and after interventions. The Searching for Hardships and Obstacles To Shots (SHOTS) survey is a standardized survey instrument to measure parental barriers to childhood immunizations. In several studies, the SHOTS survey has demonstrated consistent reliability and has been validated in diverse populations. The inclusion of the SHOTS survey instrument in studies to examine barriers to childhood immunization will provide researchers and clinicians with a better understanding of parents’ individualized barriers to immunizations. Furthermore, use of the SHOTS survey instrument to collect information about parental barriers to immunizations can lead to targeted interventions to minimize these obstacles at the individual and community level and to help us to achieve our national, state and community childhood immunization goals.
Received 13 November 2015 Accepted 26 November 2015
Healthy People 2020 goals challenge achievement of 80% of children to be immunized by age 3 in the United States.1 As researchers and clinicians, we know that different barriers exist in different communities and with different populations. Furthermore, even within communities’ immunization rate disparities exist. There is a plethora of studies examining barriers to immunizations and many intervention studies to determine the best approaches to increasing immunization rates in children. Often these intervention studies are designed to improve immunization rates without inclusion of an instrument to assess if, and what barriers, existed before the intervention, and if those barriers were reduced through the intervention. Imagine that a researcher is awarded a large grant to conduct an intervention that is aimed at minimizing parental barriers to childhood immunizations. The randomized-controlled study was designed with one outcome variable, immunization rates differences before and after the intervention. After 2–3 years of much time invested and many dollars spent, the study is complete and the researchers anxiously analyze the data. The findings are clear; there are no significant differences in immunization rates between the intervention and control groups. The researcher is left speculating about the possibility that other variables should have been considered in the study design. When designing intervention studies to examine barriers to childhood immunizations, in addition to immunization rates as the outcome variable, researchers should consider assessing barriers before and after interventions. The Searching for Hardships and Obstacles To Shots (SHOTS) survey is one example CONTACT Victoria Niederhauser © 2016 Taylor & Francis
[email protected]
KEYWORDS
childhood immunizations; instrument; intervention; parental barriers to vaccines; vaccines
of a valid and reliable instrument used in studies to understand what is interfering with optimal immunization rates in populations.2 This short (23 items) and easy to understand (4th grade reading level) survey has been reliable and validated in studies.2-5 Additionally, the SHOTS survey has been used successfully with different populations including Asian-pacific Islanders and Native Alaskans and in community, research, rural, and primary care settings. The SHOTS survey assesses three common parental barriers to immunizations including access to immunizations, concerns about immunizations and importance of immunizations. Each of the 23 items is rated on a 5-point scale indicating how much it is a problem for the parent, with the lowest score a 0 (meaning the item is not a problem at all) to a 4 (indicating this item is a very big problem). It takes about 10 minutes for parents to complete the survey. The 23 items are grouped into the 3 subscales for analysis. A total barrier to immunization score is also calculated; the higher the score, the higher the parental barriers to getting their child’s immunizations. Adding the SHOTS survey or another standardized instrument that assesses parental barriers to childhood immunizations to intervention studies can enrich study designs and provide more detailed information about which barriers were present prior to an intervention and those barriers that were reduced by an intervention. We believe that this information will add to the scientific understanding of the complex parental barriers to childhood immunizations that exist and how we can target specific barriers with innovative interventions. The hope is that
College of Nursing, University of Tennessee Knoxville, 1200 Volunteer Blvd, Knoxville, TN 37996, USA.
1294
V. NIEDERHAUSER AND C. FERRIS
armed with a greater understanding for those things that interfere with parents getting their child shots, we can ultimately create targeted interventions based on specific individual barriers and achieve our Healthy People 2020 goal and beyond. For more information or to obtain permission to use the SHOTS survey, go to www.shotssurvey.org.
[2]
[3]
Disclosure of potential conflicts of interest No potential conflicts of interest were disclosed.
References [1] US. Department of Health and Human Services (USDHHS). Healthy People. Clinical Preventive Services Leading Health Indicators, Immu-
[4]
[5]
nizations and Infectious Disease. Accessed on October 15, 2020; 2015 at http://www.healthypeople.gov/2020/topics-objectives/topic/immuni zation-and-infectious-diseases/objectives Niederhauser V. Measuring parental barriers to childhood immunizations: The development and validation of the searching for hardships and obstacles to shots (SHOTS) instrument. J Nurs Meas 2010; 18:2635; PMID:20486475; http://dx.doi.org/10.1891/1061-3749.18.1.26 Baker D, Dang M, Ly MY, Diaz R. Perception of barriers to immunization among parents of Hmong origin. Am J Public Health 2010; 100:839-45; PMID:20299651; http://dx.doi.org/ 10.2105/AJPH.2009.175935 Baker D, Melnikow Ly, MK J, Shoultz J, Niederhauser V, Diaz-Escamilla R. Translation of health surveys using mixed methods. J Nurs Scholarsh 2010; 42:430-8; PMID:21091626; http://dx.doi.org/10.1111/ j.1547-5069.2010.01368.x Baker D. Parental perceptions of barriers to immunizations among the Hmong community in Central California. ProQuest Dissertations & Theses Global 2009; 3400898
