解决免疫计划，诊所和实践的疫苗犹豫不决beplay提款次数过多

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免疫接种被认为是改善全世界健康结果的关键公共卫生干预^[1]。遗憾的是，与其他发达国家在实现儿童和青少年的最佳接受疫苗方面，加拿大并不依赖于相比良好^[2]。避免疫苗犹豫不决，定义为避免或拒绝疫苗的延迟，尽管存在疫苗接种服务，这是破坏摄取率的问题^[3.]。This practice point offers evidence-based guidance at the provincial/territorial level for immunization programs, clinics and office practices, on how best to address hesitancy and improve vaccine uptake rates. Companion documents to this practice point include two for clinicians, entitled ‘Working with vaccine hesitant parents: An update^[4.]and ‘加拿大的八元件疫苗安全系统：医疗保健工人的底漆'^[5.]

1。Detecting and addressing vaccine-hesitant subgroups

The reasons underlying vaccine hesitancy are multiple, variable and not necessarily confined to particular groups or communities^[1][3.]。Even within a given province or territory, vaccine hesitancy is not uniform but tends to occur in clusters or pockets (e.g., in a religious community or group focused on natural or non-traditional medical practices). Determining what factors underlie hesitancy in a particular locale and how best to intervene are critical steps in this process.

对于省和领土，由题为“Tailoring immunization programmes to reach underserved groups – the TIP approach’, could be particularly helpful. While guidance would need to be adapted to fit Canadian contexts, its application to different European subgroups has improved vaccine uptake significantly^[6.][7.]。关键程序的第一步是发现under-immunized subgroups in Canada. Identifying such targets is best served by having searchable provincial/territorial electronic immunization databases^[8.]。在诊所或办公实践中，当保存电子医疗记录时，可以标记免疫患者文件，以及医疗保健提供者识别的任何共同的潜在因素。在美国开发的调查工具，以识别疫苗犹豫不决的父母^[9.]could also be adapted for Canadian contexts and used at the clinic level.

2.教育所有涉及最佳实践的医疗服务提供商

Studies from many different countries have repeatedly shown that health care provider beliefs around immunization have a strong influence on patient vaccine acceptance^[10.]-[12.]The more confident health care providers are about vaccine safety and efficacy, the more parents connected with them share these beliefs. Similarly, a health care provider’s own immunization status tends to find reflection in their patients’ vaccine records. Not only do the perceptions and beliefs of health care providers have an impact on parental decision-making around immunization, but their attitudes and behaviours when working with families can also influence whether they will come forward with concerns or accept immunization^[13.]。

For optimal outcome, parents need to receive consistent and accurate information about vaccine safety and benefits from all their health care providers, and this information must be conveyed in a respectful, positive manner^[5.][14.]。To ensure continuity, immunization programs, clinics and office practices must keep all associated health care providers up-to-date with their immunization status and train them to relay information accurately and positively, especially because studies have shown that some health care providers are vaccine-hesitant themselves^[15.]。All health care providers need to be well educated on immunization benefits and safety issues, with those who are directly involved in delivery being additionally conversant regarding: best practices; the specific and serious risks of vaccine-preventable diseases; possible vaccine side effects; Canada’s adverse event surveillance systems; the importance of clear language, ‘framing’ (i.e., presumptive versus participatory approaches) and motivational interviewing techniques; and pain mitigation strategies^{[4.][5.][16.]-[18.]}。鉴于医疗保健提供者的许多压力在不同的实践领域保持最新，免疫更新应该是短暂的，有吸引力的且易于访问的。

3.利用已知的基于证据的策略增加疫苗摄取

A review of strategies known to increase vaccine uptake include:

• 瞄准under-immunized subgroups with tailored interventions^{[1][19.][20.]}。
• Making vaccine services more convenient and accessible(e.g., clinic hours and locales that better meet patient needs). Delivering the seasonal influenza vaccine through pharmacies has increased access in a number of jurisdictions^[21.]。
• Engaging community leaders,including (in specific circumstances) religious leaders, in communities with significant rates of vaccine hesitancy, to promote vaccination^[1]。
• Reminding patients by text, email or snail mail,as appropriate. Such prompts need to be built into office practice wherever routine immunizations are delivered predominately by physicians, and into public health clinics, where public health nurses give vaccines^[22.]。
• Ensu戒指统一信息在加拿大，特别是关于疫苗福利和风险，会有所帮助^[23.]。来自不同司法管辖区的矛盾信息可能会对父母和医疗保健提供者令人困惑。
• 促进和使用策略to minimize immunization pain^[18.]。
• 考虑mandates and/or incentivesfor immunization. They have been used in different jurisdictions in Canada and elsewhere but their value and effectiveness are not always clear^[24.]。
• Building trust between the immunization program and the community is foundational andcan help mitigate community vaccine confidence crises^[25.]。

4.教育儿童，青年和成年人对卫生免疫的重要性

Knowledge-building around immunization is a recognized factor in increasing vaccine uptake^[19.]-[20.], but knowledge alone is not enough. Shaping positive beliefs about immunization, among individuals and within the community, is an important contributor to uptake. Targeting hearts and minds and emphasizing vaccine acceptance as the social norm can help but more maybe needed^[26.]。Effective communication campaigns are possible even for ‘hard to reach’ groups, as has been demonstrated in Australia^[27.]。In developing a campaign it is important to remember that the same message can be heard very differently by different population subgroups^[28.]。A key element in any campaign is to evaluate its impact and then readjust as needed^[25.]。Messaging and tools should be pre-tested to ensure they are efficacious and likely to reduce hesitancy in the target group. Sharing ‘lessons learned’ and proven-effective tools and resources across jurisdictions can optimize use of time and monies. Resource-sharing becomes especially relevant when messaging non-dominant subgroups (e.g., rural remote or vulnerable inner-city youth, or a specific religious group). Evidence informed guidance on how to address vocal vaccine deniers in a public forum is available^[29.]。通过将免疫信息编织到学校课程中，帮助塑造学生的疫苗信仰和验收行为可能很好地获得了与环境问题课程，欺凌和科学宣传的课程中的类似效益^[1]。Ontario has incorporated child and youth vaccine education into their免疫2020现代化计划。Evidence is also accruing that suggests that highlighting consensus among medical scientists on the effectiveness and safety of vaccines can increase public support for vaccines^[30.]。先发制人地突出虚假权利要求，提前反驳潜在的反作用及，科学旦尼尔斯使用的突出策略表明了在接种公众反对气候变化怀疑论者的言论中的益处^[31.]。同样可能持有用于反击疫苗怀疑论者。

5.合作工作

某些省级/地区免疫方案需求与联邦政府合作最符合^[5.]and/or with leading nongovernmental organizations, such as the Canadian Paediatric Society or Canadian Public Health Association. Collaborating with respected community leaders can also broaden community support for immunization and improve uptake rates^[1]。A review of the major world religions found that most doctrines support caring for others, preserving life and community responsibilities^[32.]。只要Christian Science specifically does not support immunization and even this is not rigid。需要更广泛地认可和使用免疫的教义支持，而不仅仅是在免疫计划层面，而是由前线卫生工作者。当对疫苗提出异议时，文化或宗教社区和盟军医疗保健专业人员之间的合作工作可能有助于解决这个问题^[33.][34.]。Religious leaders communicating in partnership with health authorities during a disease outbreak can have a powerful effect, and has led to significant increases in vaccine acceptance in some communities^[34.]。

总之，通过免疫计划，诊所或办公实践需求规划以及多个利益相关者和元素的参与，在省/地区犹豫地位犹豫犹豫不决者犹豫不决。合作，量身定制的沟通，评估结果和分享经验教训是提高加拿大免疫率的关键。

Acknowledgements

This practice point was reviewed by the Community Paediatrics Committee of the Canadian Paediatric Society.

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CPS INFECTIOUS DISEASES AND IMMUNIZATION COMMITTEE

成员:Natalie A Bridger MD; Shalini Desai MD; Ruth Grimes MD (Board Representative); Timothy Mailman MD; Joan L Robinson MD (Chair); Otto G Vanderkooi MD
Liaisons:Upton D Allen MBBS, Canadian Pediatric AIDS Research Group; Tobey Audcent MD, Committee to Advise on Tropical Medicine and Travel (CATMAT), Public Health Agency of Canada; Carrie Byington MD, Committee on Infectious Diseases, American Academy of Pediatrics; Fahamie Koudra MD, College of Family Physicians of Canada; Rhonda Kropp BScN MPH, Public Health Agency of Canada; Nicole Le Saux MD, Immunization Monitoring Program, ACTive (IMPACT); Jane McDonald MD, Association of Medical Microbiology and Infectious Disease Canada; Dorothy L Moore MD, National Advisory Committee on Immunization (NACI)

Consultant:Noni E MacDonald MD

Principal authors:Noni E MacDonald MD, Eve Dubé PhD

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参考资料

1. World Health Organization. Report of the SAGE Working Group on Vaccine Hesitancy, 2014. November 2014: www.who.int/immunization/sage/meetings/2014/october/SAGE_working_group_revised_report_vaccine_hesitancy.pdf (Accessed March 28, 2017).
2. UNICEF Office Research. Innocenti Report Card 11 2013. http://www.unicef-irc.org/publications/pdf/rc11_eng.pdf
3. Dubée，麦克唐纳网。解决疫苗犹豫不决和拒绝在加拿大。CMAJ 2016; 188（1）：E17-8。
4. 麦克唐纳网，德莱斯，民主党，加拿大小儿科社会，传染病和免疫委员会。beplay贴吧使用疫苗犹豫不决的父母：更新。
5. MacDonald NE, Law BJ, Canadian Paediatric Society, Infectious Diseases and Immunization Committee. Canada’s eight-component vaccine safety system: A primer for health care workers: www.www.0513lv.com/en/documents/position/vaccine-safety-system. Paediatrics& Child Health 2017; 22 (4): 236, e13-e16.
6. Butler R, MacDonald NE; SAGE Working Group on Vaccine Hesitancy. Diagnosing the determinants of vaccine hesitancy in specific subgroups: The Guide to Tailoring Immunization Programmes (TIP). Vaccine 2015;33(34):4176-9.
7. DubéE，Leask J，Wolff B，Hickler B，Balaban v，Hosein E，HapeaaT K.世界卫生组织定制免疫计划（提示）方法：审查迄今为止疫苗2018年的实施; 36：1509-15。
8. 木D，Saarlas kn，Inkelas M，Matyas Bt。美国免疫登记处：在不断变化的医疗保健系统中对公共卫生实践的影响。安努公共卫生。1999; 20：231-55。
9. 威廉姆斯SE，Morgan A，Opel D，Edwards K，Weinberg S，Rothman R.筛选工具预测了田纳西州儿科实践中的未来枯及。2016年Clin Pediast（Phila）; 55（6）：537-42。
10. Mergler MJ, Omer SB, Pan WKY, et al. Association of vaccine-related attitudes and beliefs between parents and health care providers. Vaccine 2013;31(41):4591-5.
11. Suryadevara M，Handel A，Bonville Ca，Cibula da，Domachowske JB。儿科提供者疫苗犹豫不决：对免疫儿童的公认障碍。2015年疫苗; 33（48）：6629-34。
12. ImburgiaTM, Hendrix KS, Donahue KL, Sturm LA, Zimet GD. Predictors of influenza vaccination in the U.S. among children 9–13 years of age Vaccine. 2017;35(18):2338-2342
13. Favin M, Steinglass R, Fields R, Banerjee K, Sawhney M. Why children are not vaccinated: A review of the gray literature. Int Health 2012; 4(4):229-38.
14. Hagood EA, Mintzer Herlihy S. Addressing heterogeneous parental concerns about vaccination with a multiple-source model: A parent and educator perspective. Hum Vaccin Immunother 2013;9(8):1790-4.
15. 张j in ale，norman ij。护士中甲型流感疫苗接种的知识与态度：研究综述。疫苗2010; 28（44）：7207-14。
16. Opel DJ, Heritage J, Taylor JA, et al. The architecture of provider-parent vaccine discussions at health supervision visits. Pediatrics 2013;132(6):1037-46.
17. Leask J，Kinanderle P，Jackson C，骗子F，Bedford H，Rowles G.与父母沟通关于疫苗接种：卫生专业人士的框架。BMC PedIATR 2012; 12：154。
18. Taddio A, McMurtry CM, Shah V, et al; HELPinKids&Adults. Reducing pain during vaccine injections: Clinical practice guideline. CMAJ 2015;187(13):975-82.
19. Jarrett C，Wilson R，O'Leary M，Eckersberger E，Larson HJ;疫苗犹豫不决的圣人工作组。解决疫苗犹豫不决的策略 - 系统审查。疫苗2015; 33（34）：4180-90。
20. Dubée，Gagnon d，Macdonald Ne;疫苗犹豫不决的圣人工作组。旨在解决疫苗犹豫不决的策略：审查发布的审查。2015年疫苗; 33（34）：4191-203。
21. Buchan SA, Rosella LC, Finkelstein M, et al; Public Health Agency of Canada/Canadian Institutes of Health Research Influenza Research Network (PCIRN) Program Delivery and Evaluation Group. Impact of pharmacist administration of influenza vaccines on uptake in Canada. CMAJ 2017;189(4):E146-52.
22. Harvey H, Reissland N, Mason J. Parental reminder, recall and educational interventions to improve early childhood immunisation uptake: A systematic review and meta-analysis. Vaccine 2015;33(25):2862-80.
23. Steenbeek A, Macdonald NE, Downie J, Appleton M, Baylis F. Ill-informed consent? A content analysis of physical risk disclosure in school-based HPV vaccine programs. Public Health Nurs 2012;29(1):71-9.
24. Lee C, Robinson JR. Systematic review of the effect of immunization mandates on uptake of routine childhood immunizations Journal of Infection 2016; 72:659-666.
25. World Health Organization. Regional Office of Europe. Vaccination and Trust. 2017. http://www.euro.who.int/en/health-topics/disease-prevention/vaccines-and-immunization/publications/2017/vaccination-and-trust-2017 Accessed March 1, 2018
26. Attwell K, Smith DC. Hearts, minds, nudges and shoves: (How) can we mobilise communities for vaccination in a marketised society? Vaccine. 2017 Aug 19. pii: S0264-410X(17)31072-1. doi: 10.1016/j.vaccine.2017.08.005. [Epub ahead of print]
27. Attwell K, Freeman M. I Immunise: An evaluation of a values-based campaign to change attitudes and beliefs. Vaccine 2015; 33: 6235–6240.
28. Nyhan B Reifler J, Richey S, Freed GL. Effective messages in vaccine promotion: A randomized trial. Pediatrics 2014;133(4):e835-42.
29. Schmid P, MacDonald NE, Habersaat K, Butler R. Commentary to: How to respond to vocal vaccine deniers in public. Vaccine 2018; 36:196–198.
30. van der Linden SL, Clarke CE, Maibach EW. Highlighting consensus among medical scientists increases public support for vaccines: evidence from a randomized experiment.BMC Public Health. 2015;15:1207 Erratum BMC Public Health. 2017;17(1):284.
31. van der Linden S, Maibach E, Cook J, Leiserowitz A, Lewandowsky S. Inoculating against misinformation. Science. 2017;358(6367):1141-1142
32. Grabenstein JD。世界上的宗教教学是什么，适用于疫苗和免疫球蛋白。2013年疫苗; 31（16）：2011-23。
33. Guichon JR, Mitchell I, Buffler P, Caplan A. Citizen intervention in a religious ban on in-school HPV vaccine administration in Calgary, Canada. Prev Med 2013;57(5):409-13.
34. Kaliner E，Moran-Gilad J，Grotto I等。沉默重新引入以色列，2013年野生型脊髓灰尿病 - 2013年 - 争论争论气氛中的风险沟通挑战。2014年欧元监督; 19（7）：20703。

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Disclaimer:The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.