Vaccine Acceptance and Vaccine Policy

vaccine acceptance

The objective of vaccine acceptance/vaccine policy research at CPCE is to identify factors associated with vaccine acceptance and to develop strategies to help ensure effective implementation of immunization programs. Linked to our work investigating the changing epidemiology of vaccine-preventable diseases, our research contributes to a comprehensive understanding of the multiple factors that affect vaccine acceptance and use in order to inform the development and implementation of vaccine policy. 

We are applying behavioral theories, including the health belief model, and behavioral economics through survey methodology, qualitative methods and randomized trials to identify facilitators and barriers to vaccine use and to evaluate the effectiveness of specific interventions.

Highlights of this line of research include: 

  • Early intervention before delivery may be an important strategy to prevent under-immunization of young infants, according to a study of 65,519 newborns in Philadelphia County, with almost 13 percent not receiving their first vaccine until after three months of age. Read the abstract.
  • A prospective cohort study of pediatric clinicians in a large primary care network found that despite high intention to recommend Human Papillomavirus (HPV)‎ vaccines to 11- to 12-year -old girls, HPV vaccine series initiation rates were only 30 percent, with intention only modestly associated with the likelihood of series initiation. Read the abstract.
  • The majority of both clinical and nonclinical workers at a large pediatric hospital network agreed with a newly implemented mandatory influenza vaccination program based on their belief that it would protect patients and their previous history of vaccination for influenza. Read the abstract.
  • In a qualitative study exploring local determinants of vaccine hesitancy in Botswana and the Dominican Republic (DR), participants rely heavily on health care providers for immunization information but also report insufficient communication. What drives vaccine acceptance in the two countries differs. Read the abstract.
  • Researchers have demonstrated racial and socioeconomic difference in HPV vaccine series initiation among adolescent males that are similar to those that have been identified among females. Read the abstract.

          Read a Philadelphia Inquirer article about why pertussis is on the rise.

What’s Next

Researchers are actively working on the following studies:

  • Vaccine Acceptance in Botswana, the Dominican Republic and Greece: Impact of Media Exposure on Vaccine-Related Beliefs: This study builds upon previous work to explore determinants of vaccine acceptance in a third site, Greece, and compares the influence of different information sources across all three stites.
  • The Influence of State Mandatory Vaccination Policies on Pediatricians’ Response to Requests for Alternative Vaccine Schedules: Researchers are measuring whether the strength of mandatory school entry vaccination policies (easy vs difficult to obtain exemptions) influences how pediatricians respond to requests to delay vaccines.
  • The Impact of HPV-related Scientific Information on Intended HPV Vaccine Recommendation Behaviors among Pediatric Clinicians: Researchers are studying whether receiving information about the scientific evidence behind HPV vaccine recommendations influences how they would communicate about and recommend HPV vaccines.
  • The Effectiveness of a Video-based Educational Tool to Increase HPV Vaccine Series Initiation Among Adolescents: In this randomized trial, researchers are evaluating the effectiveness of a newly developed video-based educational tool about HPV vaccines to increase HPV vaccine acceptance among adolescent girls and boys.
  • The Effect of Human Pre-exposure History on Antigenic Drift of Influenza:  Researchers are studying how the antibody response to influenza vaccines differ when infants receive their initial two dose series with the same or different influenza vaccines.

Funding: Agency for Healthcare Research and Quality (AHRQ), National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), the Center for Pediatric Clinical Effectiveness at CHOP, The Children’s Hospital of Philadelphia Vaccine Education Center, the Leonard Davis Institute of Health Economics at the University of Pennsylvania

Please contact Kristen A. Feemster, MD, MPH, MSHP, a CPCE core faculty member, research director for the Vaccine Education Center at CHOP, assistant professor of Pediatrics, the Perelman School of Medicine at the University of Pennsylvania, and an attending physician in the division of Infectious Diseases at CHOP, for more information about this line of research.

Vaccine Acceptance/Vaccine Policy Published Research

Feemster KA, Winters SE, Fiks A, Kinsman S, Kahn, JA.  Pediatricians' intention to recommend human papillomavirus (HPV) vaccines to 11- to 12-year-old girls postlicensing. Journal of Adolescent Health. 2008 Oct;43(4) 408-11.

Feemster KA, Spain CV, Eberhard M, Pati S, Watson B. Identifying infants at increased risk for late initiation of immunizations: maternal and provider characteristics. Public Health Reports. 2009 Jan; 124(1): 42-53.

Feemster KA, Kahn JA. Human papillomavirus immunization: implementation of recommendations. Contemporary Pediatrics. 2010 June 1; 27(6):34-43.

Pati S, Feemster KA, Mohamad Z, Fiks A, Grundmeier R, Cnaan A. Maternal Health Literacy and Late Initiation of Immunizations among an Inner-city Birth Cohort. Maternal and Child Health Journal. 2011 Apr.; 15(3):386-94.

Feemster KA, Prasad P, Smith MJ, Feudtner C, Caplan A, Offit P, Coffin S. Employee Designation and Health Care Worker Support of an Influenza Vaccine Mandate at a Large Pediatric Tertiary Care Hospital. Vaccine. 2011 Feb 17; 29(9):1762-6.

Kahn JA, Feemster KA, Hillard PJA. HPV Vaccination: Do Your Patients Get the Message? Contemporary Obstetrics and Gynecology. 2011 March 1; 56(3): 24-31.

Hughes CC, Jones AL, Feemster KA, Fiks A. HPV vaccine decision making in pediatric primary care: a semi-structured interview study. BMC Pediatrics. 2011 Aug 30;11:74.

Mayne S, Karavite D, Grundmeier RW, Localio R, Feemster K, DeBartolo E, Hughes CC, Fiks AG. The Implementation and Acceptability of an HPV Vaccination Decision Support System Directed at Both Clinicians and Families. AMIA Annu Symp Proc. 2012 Nov 3; 2012:616-624.

Fiks AG, Grundmeier RW, Mayne S, Song L, Feemster K, Karavite D, Hughes CC, Massey J, Keren R, Bell LM, Wasserman R, Localio AR. Effectiveness of Decision Support for Families, Clinicians, or Both on HPV Vaccine Receipt. Pediatrics. 2013 Jun;131(6):1114-24.

Feemster KA and Offit P. Delaying vaccination is not a safer choice. JAMAPediatrics. 2013 Dec; 167(12):1097-8.

Feemster KA. Overview: special focus vaccine acceptance. Human Vaccines and Immunotherapeutics. 2013 Aug 1; 9(8).

Feemster KA. Can building evidence move a persistent vaccine safety concern? Pharmacoepidemiology and Drug Safety. 2013 Dec;22(12):1271-3. 2013.

Feemster KA, Offit P. "Compassionate use" for public health. Annals of Internal Medicine. 2013 Dec 24; 160(6):421-422.

Opel D, Feemster K, Omer S, Orenstein W, Richter M, Lantos J. A 6-month-old with vaccine-hesitant parents. Pediatrics. 2014 Feb 10; 133(3):526-30.

Rentmeester CA, DasGupta R, Feemster KA, Packard RM. Coercion and polio eradication efforts in Moradabad. Human Vaccines and Immunotherapeutics. 2014; 8-10(4)

Feemster, KA. Delay in measles vaccination is associated with increased risk of post-vaccination seizures. Journal of Pediatrics. 2014 Mar;164(3):672-6.

Mayne SL, duRivage NE, Feemster KA, Localio AR, Grundmeier RW, Fiks AG. Effect of decision support on missed opportunities for Human Papillomavirus vaccination. Am J Prev Med. 2014 Dec;47(6):734-744.

Feemster KA, Middleton M, Fiks A, Winters SE, Kinsman SB, Kahn JA. Does Intention to Recommend HPV Vaccines Impact HPV Vaccination Rates? Human Vaccines and Immunotherapeutics, 2014 Oct 30; 10(9), 2519-2526.

Agawu A, Buttenheim A, Taylor L, Song L, Fiks AG, Feemster KA.  Sociodemographic Differences in Human Papillomavirus Vaccine Initiation by Adolescent Males. Journal of Adolescent Health. 2015 Sept 15; S1054-139X(15)00281-5.

Feemster KA. Remembering the benefits of vaccination. JAMA Pediatr. 2015 Jul 1;169(7):624-6.

Kestenbaum LA, Feemster KA. Identifying and addressing vaccine hesitancy. Pediatr Annals. 2015 Apr;44(4):e71-5.


Feemster K, Prasad P, Feudtner C, Smith M, Offit P, Caplan A, Coffin S.  All On the Line: Attitudes Toward Mandatory Influenza Vaccination Among Health Care Workers (#868). Infectious Diseases Society of America Annual Meeting- Oral Abstract Session. Vancouver, Canada: October 2010.

Fiks AG, Hughes C, Jones A, Feemster K. HPV Vaccine Communication and Decision Making in Pediatric Primary Care. Oral Presentation at the 2011 6th International Shared Decision Making Conference, Maastricht, The Netherlands, June 19, 2011.

Buttenheim A, Middleton M, Fiks A, Coffin SE, Metlay J, Feemster KA.  Can Retail Pharmacy Vouchers Increase Tdap Vaccination for Infant Caregivers? Results from a Randomized Pilot Study (Abstract #:754139) Pediatric Academic Societies Annual Meeting- Platform Session. Vancouver, Canada: May 2014.

Mayne S, Localio R, Grundmeier R, Feemster KA, Fiks A.  Effect of Clinician and Family-Focused Decision Support on Missed Opportunities for HPV Vaccination Among Adolescent Girls: A Randomized Trial (Abstract #: 751377). Pediatric Academic Societies Annual Meeting- Platform Session. Vancouver,Canada: May 2014.

Kestenbaum L, Steenhoff AP, Nfila BF; Moser CA; Monyatsi N; Murphy M; Luberti AA; Offit PA; Shea J; Feemster KA. The Impact of Media on Vaccine Attitudes and Knowledge Among Caregivers and Health Care Providers in Botswana (Abstract #:751454). Pediatric Academic Societies Annual Meeting- Poster Session. Vancouver, Canada: May 2014.

Kestenbaum LA; Steenhoff AP, Nfila BF; Moser CA; Monyatsi N; Murphy M; Luberti AA; Offit PA; Shea JA; Feemster KA. The healthcare system as a facilitator and barrier to vaccine acceptance in Botswana: public trust, communication and vaccine delivery.  European Society for Pediatric Infectious Diseases Annual Meeting. Dublin, Ireland: May 2014.

Kestenbaum LA, Steenhoff AP,  Murphy M, Callender M, Japa I, Nfila BF, Moser C,  Monyatsi N, Offit PA, Feemster KA.  A comparison of local determinants of vaccine hesitancy in Botswana and the Dominican Republic, two-middle income countries. Infectious Diseases Society of America Annual Meeting. Philadelphia, PA: October 2014.