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Background: Vaccination of pregnant people with a vaccine containing acellular pertussis (tetanus–diphtheria–acellular pertussis [Tdap]) has been recommended in Canada since 2018, and the evaluation of delivery models for efficient maternal Tdap administration is a priority for the Quebec Ministry of Health. We implemented 3 vaccine delivery models, in addition to the existing standard of practice model, and compared the vaccine coverage achieved by the 4 models in Quebec. Methods: In this quasiexperimental, multicentre observational study, we recruited pregnant people at less than 21 weeks’ gestation in 4 Quebec regions from April to October 2019. We compared 4 vaccine delivery models: local community service centres (centre local de services communautaires [CLSCs], baseline), family medicine groups (FMGs), obstetrics clinic and the oral glucose challenge test (OGCT). In addition to the CLSCs, 3 FMGs, 1 obstetric clinic and a hospital-based OGCT screening program participated. We determined vaccination status from a self-reported questionnaire, the Quebec Immunization Registry or medical charts. We compared model-specific (for participants recruited to a model and subsequently vaccinated within that model) and overall vaccine coverage (considering all vaccine delivery pathways) and used logistic regression to adjust for sociodemographic variables. Results: Overall, 946 of 1000 recruited pregnant people were eligible for analyses. Vaccination via the FMGs achieved the highest model-specific vaccine coverage (67.8%, 95% confidence interval [CI] 60.5%–74.4%), but coverage was not significantly different from the CLSCs (63.8%, 95% CI 57.6%–69.6%). For overall vaccine coverage, the FMG (86.5%, 95% CI 80.6%–90.9%) and obstetrics models (85.9%, 95% CI 80.9%–89.7%) achieved significantly higher vaccine coverage than the CLSCs (66.3%, 95% CI 60.1%–71.9%). The OGCT model did not improve overall vaccine coverage (61.8%, 95% CI 56.1%–67.2%). Interpretation: Compared with CLSCs, overall vaccine coverage was higher when Tdap was offered in FMGs or an obstetrics clinic providing prenatal care. Health professionals involved in pregnancy follow-up recommending and offering the vaccine may be a key factor in optimizing vaccine coverage.

Background In Canada, vaccination against pertussis (Tdap) during pregnancy has been recommended since 2018, with suboptimal uptake. We aimed to assess the determinants of intention and uptake of Tdap vaccine among pregnant women in Quebec. Methods Participants ( 35 weeks). One measured vaccination intention and the other assessed the actual decision. Questionnaires were informed by the Theory of Planned Behaviour (TPB). We used logistic multivariate analysis to identify determinants of Tdap vaccination uptake during pregnancy using responses to both questionnaires. Results A total of 741 women answered the first survey and 568 (76.7%), the second survey. In the first survey most participants intended to receive the Tdap vaccine during their pregnancy (76.3%) and in the second survey, 82.4% reported having been vaccinated against Tdap during their pregnancy. In multivariate analysis, the main determinants of vaccine uptake were: a recommendation from a healthcare provider (OR = 7.6), vaccine intention (OR = 6.12), social norms (or thinking that most pregnant women will be vaccinated (OR = 3.81), recruitment site (OR = 3.61 for General Family Medicine unit) perceived behavioral control (or low perceived barriers to access vaccination services, (OR = 2.32) and anticipated feeling of guilt if not vaccinated (OR = 2.13). Safety concerns were the main reason for not intending or not receiving the vaccine during pregnancy. Conclusion We observed high vaccine acceptance and uptake of pertussis vaccine in pregnancy. The core components of the TPB (intention, social norms and perceived behavioral control) were all predictors of vaccine uptake, but our multivariate analysis also showed that other determinants were influential: being sufficiently informed about Tdap vaccination, not having vaccine safety concerns, and anticipated regret if unvaccinated. To ensure high vaccine acceptance and uptake in pregnancy, strong recommendations by trusted healthcare providers and ease of access to vaccination services remain instrumental.

Background Monitoring vaccination coverage is an essential component of vaccination program evaluation. In Quebec (Canada), children vaccination coverage surveys are conducted every two years since 2006. The objectives of this study were to evaluate the impact of supplementing data based on vaccination booklets with data from vaccine providers, on the final estimated vaccination coverage and to compare vaccination coverage between respondents to each survey contact attempt. Methods Data from six cross-sectional surveys were used, which included 3508 children aged 2 years. Parents were invited to transcribe the information available in their child’s vaccination booklet on the questionnaire received by mail. The survey included a maximum of 4 contact attempts to obtain a response. Data were completed among vaccine providers identified by parents. The main outcome was a complete vaccination status by 24 months of age. Results The addition of data from vaccine providers to those present in vaccination booklets increased the proportion of children fully vaccinated from 5.5% to 23.7% depending on the survey year. The proportion of children fully vaccinated by 24 months of age estimated among respondents to contact 1 was only 2.1% higher than the estimates among all respondents. Conclusions Without validation among vaccine providers for children with missing doses according to vaccination booklets, results underestimated vaccination coverage in the target population. Conducting multiple contact attempts increased the response rate but had limited impact on the validity of estimates. It would be useful in future surveys to present the coverage obtain from respondents to each contact attempt.

Multicomponent interventions are effective in improving vaccine coverage. However, few studies have assessed their effect on timely vaccination. The aim of this study was to compare the proportion of children with vaccine delays at 2- and 12-month visits according to whether or not health centers have participated in an action research project on the organization of vaccination services for 0-5-year-olds. The action research project included a multicomponent intervention and was conducted between 2011 and 2015 in Quebec, Canada. An ecological before/after design was used for this analysis. A total of 264,579 DTaP-IPV-Hib (2-month visits) and 240,541 Men-C-C (12-month visits) vaccine doses were administered during 2011–2012 to 2014–2015 fiscal years, including 19% in 14 participating health centers and the remaining in 78 nonparticipating centers. Vaccine delays demonstrated a more pronounced decreasing trend in participating versus nonparticipating health centers (p

Context Between 2004 and 2016, in the province of Quebec (Canada), 4 new antigens were added in the early childhood vaccine schedule from birth to 18 months, increasing the number of injections or doses needed from 7 to 12. These additions may have decreased the proportion of children who had received all recommended vaccines. Objectives To assess the impact of the introduction of new vaccines to the childhood schedule on the 24-month vaccine coverage from 2006 to 2016 and identify factors associated with incomplete vaccination status by 24 months of age. Methods We used the data from six cross-sectional vaccine coverage surveys conducted every two years which included a total of 3515 children aged 2 years old and randomly selected from the Quebec public health insurance database. Factors associated with an incomplete vaccine status by 24 months were identified with multivariable logistic regression. Results Despite the addition of 4 new vaccine antigens since 2004, the vaccine coverage remained high from 2006 (82.4%) through 2016 (88.3%) for vaccines present in the schedule since 2006. In 2016, vaccine coverage was 78.2% for all vaccines included in the schedule. The vaccine coverage of new vaccines increases rapidly within 2 years of their introduction. For both new and older vaccines, incomplete vaccine status by 24 months of age is associated with a delay of 30 days or more in receiving the vaccines scheduled at 2 and 12 months of age. Conclusions Increasing to 12 the number of doses in the recommended schedule has slightly reduced the vaccine coverage by 24 months of age and the vaccine coverage of vaccines already in the schedule remained stable over the years. Future additions to the vaccine schedule may not be similarly accepted by the population and this will require continuing the monitoring of vaccine coverage.

Objective To test an intervention designed to motivate older adults in documenting their healthcare preferences in advance, and to guide proxies in making hypothetical decisions that match those of the older adult. Methods The trial involved 235 older adults, of which half were assisted in communicating their wishes to their proxy. Hypothetical vignettes were used at baseline and twice after the intervention to elicit older adults’ preferences and assess their proxy’s ability to predict them. Results By the end of the trial, 80% of older adults allocated to the experimental group had documented their wishes. Changes over time in mean accuracy scores did not differ between groups for any hypothetical situations, except when limiting the sample to dyads that were highly discordant at baseline. Conclusion The intervention motivated a large proportion of older adults to express their preferences but had little effect on proxies’ ability to predict them. Practice implications Educational tools developed for this study will assist healthcare providers in helping older adults to record their wishes in advance. Clients must be informed of the challenge of making substitute decisions and of the need to discuss the amount of leeway the proxy should have in interpreting expressed wishes.

Primary prevention of human papillomavirus (HPV) through vaccination is a high priority in Canada's cancer prevention efforts. All Canadian provinces and territories have introduced publicly funded, school-based vaccination programs against HPV, but vaccine uptake remains suboptimal in some jurisdictions. We conducted a descriptive qualitative study to better understand the determinants of low HPV vaccine uptake and identify strategies to enhance vaccine acceptance using the socio-ecological model. In Quebec, interviews and focus groups were held in 2015-2016 with 70 key informants including immunization managers, school nurses, school principals, teachers and parents of Grade 4 students (9 years of age). Our findings showed that HPV vaccine uptake was dependent on many interrelated factors at the individual and interpersonal level (e.g. knowledge and attitudes of the different players involved in the vaccination system), at the community level (e.g. social group values and norms, media coverage around the HPV vaccine), at the organizational level (e.g. allocated resources, information provision, consent process, immunization setting and environment) and at the policy level (e.g. changes in provincial HPV vaccine program). We are using the data collection and interpretation tools and approaches developed by our team and used in Quebec to expand our study to four other provinces (British Columbia, Alberta, Ontario and Nova Scotia). We are conducting environmental scans, semi-structured interviews and a survey to better understand the determinants of low HPV vaccine uptake and identify strategies to enhance vaccine acceptance. Having an in-depth understanding of the determinants of HPV vaccination in school settings is critical in order to identify root causes of the suboptimal vaccine uptake and to develop tailored interventions to address these on both supply- and demand-side issues.

Objective Influenza vaccine uptake among Canadian pregnant individuals is suboptimal. Failure to incorporate vaccination into routine prenatal care and a lack of recommendations from healthcare providers are recognized as barriers to vaccination. The aim of this study was to assess Canadian maternity care providers’ knowledge, attitudes, and practices regarding influenza vaccination in pregnancy. Methods A cross-sectional Web-based questionnaire was sent during July and August 2017 to family physicians, obstetricians-gynaecologists, midwives, pharmacists, and nurses who care for pregnant individuals. A multivariable logistic regression model was used to determine variables independently associated with providers’ recommendation of the influenza vaccine in pregnancy. Results The analysis included 1061 providers. Most participants (85%) reported being vaccinated against influenza themselves, and 72% reported recommending the influenza vaccine to all of their pregnant patients during the previous influenza season. Participants’ attitudes regarding influenza vaccination during pregnancy were generally positive: 64% strongly agreed that pregnant individuals are at an increased risk of complications from influenza, and 69% strongly agreed that it is safe to vaccinate pregnant individuals against influenza. The main determinants of participants’ recommendations for influenza vaccination to all pregnant patients were following official recommendations on influenza vaccination, discussing vaccines with most or all pregnant individuals seen in their practice, and being vaccinated themselves during the previous influenza season. Conclusion Enhancing influenza vaccine uptake in pregnancy is largely dependent on maternity care providers’ recommendations. This study provides valuable insight on providers’ knowledge, attitudes, and practices.

Background A point‐of‐care rapid test (POCRT) may help early and targeted use of antiviral drugs for the management of influenza A infection. Objective (i) To determine whether antiviral treatment based on a POCRT for influenza A is cost‐effective and, (ii) to determine the thresholds of key test parameters (sensitivity, specificity and cost) at which a POCRT based‐strategy appears to be cost effective. Methods An hybrid « susceptible, infected, recovered (SIR) » compartmental transmission and Markov decision analytic model was used to simulate the cost‐effectiveness of antiviral treatment based on a POCRT for influenza A in the social perspective. Data input parameters used were retrieved from peer‐review published studies and government databases. The outcome considered was the incremental cost per life‐year saved for one seasonal influenza season. Results In the base‐case analysis, the antiviral treatment based on POCRT saves 2 lives/100 000 person‐years and costs $7600 less than the empirical antiviral treatment based on clinical judgment alone, which demonstrates that the POCRT‐based strategy is dominant. In one and two way‐sensitivity analyses, results were sensitive to the POCRT accuracy and cost, to the vaccination coverage as well as to the prevalence of influenza A. In probabilistic sensitivity analyses, the POCRT strategy is cost‐effective in 66% of cases, for a commonly accepted threshold of $50 000 per life‐year saved. Conclusion The influenza antiviral treatment based on POCRT could be cost‐effective in specific conditions of performance, price and disease prevalence.

Background: Communicating wishes regarding future research participation in the event of incapacity may help others make enrollment decisions that are more consistent with these wishes. We tested whether an advance planning intervention (1) motivated older adults to document their wishes regarding future research participation and (2) guided proxies in making hypothetical research decisions that agreed with those of the older adult. Methods: This randomized trial involved 235 dyads of older adults and proxies. The experimental intervention consisted of a group information session on advance directives, coupled with two encounters with a facilitator who helped older adults communicate their wishes to their proxy. Control participants attended three educational workshops on healthy behaviors. Short descriptions of hypothetical studies were used at baseline and twice post intervention to elicit older adults' and proxies' decisions regarding study enrollment. Answers were elicited under four health st...

Le fardeau des maladies chroniques commande de repenser l’organisation des services et la prestation des soins. Des amenagements parfois organisationnels, parfois legislatifs permettent aux non-medecins d’etre plus actifs dans le suivi des maladies chroniques. Au Quebec, depuis 2003, une nouvelle structure organisationnelle, les groupes de medecine de famille, et une nouvelle modalite d’ordonnance medicale, les ordonnances collectives (OC), se deploient progressivement. Un cas-type a ete retenu parmi 52 participants a une enquete provinciale afin d’explorer les retombees des OC sur les pratiques professionnelles, les interactions medecin-infirmiere-patient et l’autogestion dans le contexte du suivi diabetique. Quinze heures d’observation, 200 documents et des entrevues individuelles aupres de dix patients, trois infirmieres et huit medecins ont ete analyses. Unanimement, les participants reconnaissent que l’autogestion est stimulee par le suivi conjoint. Bien que des conditions liees aux professionnels et aux patients modulent leurs interactions, la triade s’orchestre efficacement selon un mouvement de convergence. Pour les professionnels, les OC permettent une meilleure concordance entre leur emploi du temps, leurs competences et le sens qu’ils accordent a leur pratique. Pour les patients, la progression de leurs competences a l’autogestion et l’acces aise aux soins sont rassurants. Des moyens concrets comme les OC modifient la prestation des soins en misant sur la collaboration professionnelle et facilitent la mobilisation des patients, en accord avec le Chronic Care Model (CCM) [1].

• Over the implementation period, prioritized interventions were implemented or strengthened in many vaccination clinics.

Even if vaccination is often described as one of the great achievements of public health, results of recent studies have shown that parental acceptance of vaccination is eroding. Health providers’ knowledge and attitudes about vaccines are important determinants of their own vaccine uptake, their intention to recommend vaccines to patients and the vaccine uptake of their patients. The purpose of this article is to compare how midwives and physicians address vaccination with parents during pregnancy and in postpartum visits. Thirty semi-structured interviews were conducted with midwives and physicians practicing in the province of Quebec, Canada. Results of our analysis have shown that physicians adopt an “education-information” stance when discussing vaccination with parents in the attempt to “convince” parents to vaccinate. In contrast, midwives adopted a neutral stance and gave information on the pros and cons of vaccination to parents while leaving the final decision up to them. Findings of this study highlight the fact that physicians and midwives have different views regarding their role and responsibilities concerning vaccination. It may be that neither of these approaches is optimal in promoting vaccination uptake.

Cette étude qualitative s’intéresse aux modes d’organisation des équipes de première ligne en santé mentale jeunesse de la Montérégie. Cette région compte onze de ces équipes qui disposent de modalités de fonctionnement différentes et oeuvrant au sein de contextes diversifiés. La collecte des données a été effectuée en 2010 et 2011. L’étude décrit les pratiques actuelles selon la perspective des membres de ces équipes et les modalités de collaboration qu’elles ont préconisées avec leurs différents partenaires, un enjeu majeur lorsqu’une équipe oeuvre au sein d’un réseau intégré de services. Une taxonomie fut élaborée afin de mieux apprécier le potentiel d’amélioration et de faire ressortir des pistes tangibles tant pour les gestionnaires que pour les professionnels de ces équipes., This qualitative study examines the organizational models of a primary mental health care team for youths in the Montérégie region. This region includes eleven teams working according to different modalities of functioning and within varied contexts. Data was collected in 2010 and 2011. The study describes current practices according to the perspective of members of these teams and modes of collaboration advocated by their different partners, a major issue when a team works within an integrated network of services. A taxonomy was elaborated in order to better appreciate the potential for improvement, and to highlight tangible avenues as much for management as for professionals of these teams.

Despite being recognized as one of the most successful public health measures, vaccination is perceived as unsafe and unnecessary by a growing number of individuals. Lack of confidence in vaccines is now considered a threat to the success of vaccination programs. Vaccine hesitancy is believed to be responsible for decreasing vaccine coverage and an increasing risk of vaccine-preventable disease outbreaks and epidemics. This review provides an overview of the phenomenon of vaccine hesitancy. First, we will characterize vaccine hesitancy and suggest the possible causes of the apparent increase in vaccine hesitancy in the developed world. Then we will look at determinants of individual decision-making about vaccination.

Background Immunization rates are used to assess the level of protection against influenza, but limited data exist on how such rates are measured in health care organizations. We conducted key informant interviews with campaign planners to learn about processes for collecting immunization data, including barriers and facilitating factors for measuring and reporting rates. Methods We conducted telephone interviews with 23 influenza immunization program planners across Canada working in 7 acute care hospitals, 6 continuing care facilities, and 8 public health organizations in 2012. We used content analysis to examine the interview data. Results The methods used to collect immunization data varied by the size and type of health care organization. Immunization data from different personnel groups were included in immunization rate calculations depending on the local public health reporting requirements and the organization's size. Challenges associated with collecting immunization data and calculating rates included lack of resources for identifying personnel immunized off-site, tracking personnel who declined immunization, identifying non-payroll staff, and interpreting unclear public health reporting requirements. Conclusion Support from other vaccine providers, public health, employers, and professional and external bodies is needed to provide the necessary information and resources to calculate accurate and complete rates. Further work is needed to refine and standardize the collection of HCW influenza immunization data so that it may be used for surveillance and quality assessment purposes.

Background In response to the need for improved quality of vaccine inventory and client immunization records, barcodes containing a unique identifier and lot number will be placed on all vaccine vials in Canada. We conducted feasibility studies to examine integration of barcode scanning into inventory recording workflow for mass immunization clinics. Methods During the 2010–2011 seasonal influenza vaccination campaign, Ontario public health units (PHUs) using an electronic immunization system were randomized to record clinic inventory data (including vaccine lot number and expiry date) through: (i) barcode scanning of vials; or (ii) drop-down menus. A third group of PHUs recording vaccine inventory on paper served as an observation arm. We visited a sample of clinics within each PHU to assess barcode readability, method efficiency and data quality. Clinic staff completed a survey examining method perceptions. Results We observed 20 clinics using barcode scanning to record inventory data (eight PHUs), 20 using drop-down menus (eight PHUs), and 21 using paper forms (five PHUs). Mean time spent recording data per vial was 4.3 s using barcode scanners with 1.3 scan attempts per vial, 0.5 s using drop-down menus, and 1.7 s using paper. Few errors were observed. Sixty-four perception surveys were completed by inventory staff; barcode scanning users indicated fairly strong overall satisfaction with the method (74%), and the majority agreed that barcode scanning improved client safety (84%) and inventory record accuracy (77%). However, 38% of barcode scanning users felt that individually scanning vials took longer than the other approaches and 26% indicated that this increased time would discourage them from adopting the method. Conclusions Our study demonstrated good readability of barcodes but scanning individual vials for high-volume clinics was time-consuming; modifying the process will improve feasibility to facilitate adoption in Canada, while serving as an example for other countries considering this technology.

Objectives: A critical component of the 2009 H1N1 vaccination campaign was the collection of immunization data at the point of care. To meet reporting requirements and to ensure timely availability of coverage information, many jurisdictions across Canada employed new or modified approaches to vaccine data collection. The objective of this study was to observe and characterize the range of influenza immunization data collection approaches used across Canada. Methods: As part of a multi-stage observational study, the research team visited immunization clinics at which tasks related to data collection and management were observed.Tasks included registration, medical history collection and review, vaccine record-keeping, proof of vaccination preparation, and data entry. Field notes were analyzed in order to understand the data collection mechanisms that comprised each information system as a whole. Results: Data collection mechanisms were grouped into two categories: electronic systems (9/38), in which all data were captured on computer; and hybrid systems (29/38), comprised of computerized and paper-based data collection tasks. Observed systems included stand-alone databases, immunization registries, and electronic health records. Organizations incorporated magnetic card reader technology, telephone registration, and pre-populated fields into data collection approaches. Electronic systems captured a greater number of data elements. Conclusion: Canadian jurisdictions employed a range of data collection approaches during the H1N1 vaccination campaign. System characteristics can have important implications for on-site efficiency and organization as well as program planning and evaluation. The systems observed have been described in detail to allow vaccine providers and planners to learn from what has been done elsewhere. Key words: Influenza; human; immunization; information systems

During the pandemic (H1N1) 2009 vaccination campaign, vaccine providers collected immunization data using hybrid (paper-based and electronic methods) and electronic data systems. We measured staff time in seconds spent on data collection tasks to compare system efficiencies. The sample consisted of 38 organizations across nine Canadian provinces/territories. The total mean data collection times per client were 104 s (electronic system), 143 s (hybrid system with electronic registration) and 172 s (hybrid system with paper registration). Electronic registration and record keeping were faster than paper-based methods; these findings should be used to improve data collection for future influenza seasons.

OBJECTIVE This study aimed to explore the impact of adding new vaccines on schedule adherence and parental opinion of multiple injections. METHOD A descriptive cross-sectional study by self-administered questionnaire mailed to a stratified random sample of each of two cohorts of children drawn from the Monteregie Birth Register: the 2002-2003 cohort (old vaccination schedule) and the 2004-2005 cohort (new schedule). Two surveys were done: Survey 1 (fall 2005-winter 2006) questioned parents whose address could be validated by Canada411.ca; Survey 2 (fall 2006) surveyed parents whose address was validated by the Quebec health insurance board (RAMQ). Incomplete or missing vaccine data were completed by verifying the vaccinators' files. RESULTS Analysis of schedule adherence by the Kaplan-Meier survival approach showed that the 2nd and 3rd doses of the DTaP-P-Hib vaccine were received late by the youngest children compared to the oldest (median number of days late: 2 days for the 2nd vaccine (p = 0.013) and 4 days for the 3rd vaccine (p < 0.001)). Many parents (76%) prefer 2 to 3 injections during a single visit, and 61% fear an increase in the risk of side effects. CONCLUSION Even if the evaluated lateness has only a small public health impact, parents must be reassured about the safety of multiple vaccines.

Background: In Quebec, the pneumococcal conjugate vaccine was available on the private market as early as 2001 and has been included in the publicly funded immunization program since December 2004. Objectives: To compare the advantages and limitations of two different sources for assessing vaccination coverage in the target population of children and to evaluate the impact of the public health program on uptake rates. Methods: Data from a province-wide survey of a random sample of parents and from the Quebec City Immunization Registry were used to compute vaccination rates over time in different population groups. Results: Data from the immunization survey and the regional registry were congruent regarding trends. Immunization rates were overestimated, more in the registry than in the survey. During the 2001-2004 period, uptake rates were low, and many children received fewer than the recommended number of doses. As soon as free vaccination was granted, uptake increased markedly and close to 90% of children received the recommended three doses, the level required for inducing herd effects. Delay in the administration of the third booster dose was observed. Conclusions: Free vaccination is a major determinant of vaccine uptake and should remain a fundamental principle of the Canadian health system. Key words: Evaluation study; immunization; pneumococcal vaccine

“Vaccine hesitancy” is a concept now frequently used in vaccination discourse. The increased popularity of this concept in both academic and public health circles is challenging previously held perspectives that individual vaccination attitudes and behaviours are a simple dichotomy of accept or reject. A consultation study was designed to assess the opinions of experts and health professionals concerning the definition, scope, and causes of vaccine hesitancy in Canada. We sent online surveys to two panels (1- vaccination experts and 2- front-line vaccine providers). Two questionnaires were completed by each panel, with data from the first questionnaire informing the development of questions for the second. Our participants defined vaccine hesitancy as an attitude (doubts, concerns) as well as a behaviour (refusing some / many vaccines, delaying vaccination). Our findings also indicate that both vaccine experts and front-line vaccine providers have the perception that vaccine rates have been declining and consider vaccine hesitancy an important issue to address in Canada. Diffusion of negative information online and lack of knowledge about vaccines were identified as the key causes of vaccine hesitancy by the participants. A common understanding of vaccine hesitancy among researchers, public health experts, policymakers and health care providers will better guide interventions that can more effectively address vaccine hesitancy within Canada.

CONTEXT: Despite the implementation of a Quebec immunization program against influenza and pneumococcal disease (PQIIP), vaccine coverage has remained low. There have been many studies on personal barriers to vaccination, but few have explored other kinds of barriers. OBJECTIVES: To explore the presence of barriers in relation to the organization of the health care system and to propose recommendations for increasing vaccine coverage. METHODS: Within a mixed protocol, a phone survey of 996 people in the target population and a case study implicating the follow-up of the PQIIP with all the site and actor categories via 43 semi-structured interviews and 4 focus groups were realized. Survey data underwent a descriptive statistical analysis. Qualitative analysis followed the Miles and Huberman approach. RESULTS: The results indicate the presence of barriers with regard to information accessibility. These include access to: the physicians’ recommendation, knowledge of the efficacy or the security of vaccines, and admissibility of clients to the PQIIP. Organizational barriers were also found to limit access to vaccination, especially in terms of restricted choices of time and location. Coordination and incentives mechanisms are not optimal. Removal of organizational barriers depends more on strategic rather than structural factors. CONCLUSION: Addressing organizational barriers should be an important component of strategies aimed at improving vaccine coverage. Public health authorities should focus on strategic management of the information and inter-organizational environment.

The burden of chronic disease requires a new organization of medical care and services. Enhancing collaboration among front-line care givers facilitates access to care and optimizes follow-up. As a result, a new organizational structure has been gradually deployed in Quebec since 2003. Family Medicine Groups (FMGs) use a new type of standing order, prescribing details of care. Among 52 FMGs surveyed, an exemplarygroup was identified that most successfully instituted more and higher-impact standing orders. This single case study explored the impact of standing orders used for diabetes follow-up on professional practices, physician-nurse-patient interactions and patient self-management. The data collected and analyzed were derived from more than 200 documents, 15 hours of observation in the clinic, and individual interviews of ten patients, three nurses and eight doctors. Standing ordersformalizing thejointfollow-up ofdiabetic patients both increased professional collaboration and improved patient-professional interactions. As professionals and patients achieved a better consensus, patient self-management was improved. Ultimately, for professionals, standing orders facilitate a better match between the use of their time and skills, and their aspirationsfor practice. Patients are reassured and empowered by ready access to care and their progress in self-management skills. Concrete measures, such as standing orders, modify care delivery by reinforcing professional collaboration, and facilitate patient self-care, in accordance with the Chronic Care Model (CCM).

This study compares the cost-effectiveness of a control strategy for serogroup C meningococcal disease (CMD) relying on surveillance and implementation of a mass immunization campaign effective 1 year after the beginning of an epidemic with strategies based on routine immunization, using either three doses of serogroup C conjugate vaccine given in early infancy or one dose at 1 year of age. The simulation model is based on 25 birth cohorts followed up to age 24 years, and seven epidemiological scenarios including low and high level endemicity, and one to five epidemics over a 49-year period. Epidemiological and cost data were mainly collected in the province of Quebec, Canada. Results indicate that the most effective strategy is a three-dose routine program, with the least effective strategy being mass immunization. A one-dose routine program is the most cost-effective strategy in most likely scenarios. In a societal perspective with a vaccine purchase price of CDN$ 50 per dose, the average incremental cost of the one-dose strategy would be $ 190,000 per case averted, US$ 23,000 per life-year gained, and US$ 42,000 per QALY gained. If vaccine-induced immunity is waning rapidly, mass immunization or routine vaccination with booster dose(s) would be the best control options.

To estimate cost-effectiveness of routine and catch-up vaccination of Canadian children with seven-valent pneumococcal conjugate vaccine, a simulation model was constructed. In base scenario (vaccination coverage: 80%, and vaccine price: 58 dollars per dose), pneumococcal disease incidence reduction would be superior to 60% for invasive infections, and to 30% for non-invasive infections, but the number of deaths prevented would be small. Annual costs of routine immunization would be 71 million dollars (98% borne by the health system). Societal benefit to cost ratio would be 0.57. Net societal costs per averted pneumococcal disease would be 389 dollars and 125,000 per life-year gained (LYG). Vaccine purchase cost is the most important variable in sensitivity analyses, and program costs would be superior to societal benefits in all likely scenarios. Vaccination would result in net savings for society, if vaccine cost is less than 30 dollars per dose. Economic indicators of catch-up programs are less favorable than for routine infant immunization.

Parents’ decision to use vaccination services is complex and multi-factorial. Of particular interest are “vaccine-hesitant” parents who are in the middle of the continuum between vaccine acceptance and refusal. The objective of this qualitative longitudinal study was to better understand why mothers choose to vaccinate—or not—their newborns. Fifty-six pregnant mothers living in different areas of Quebec (Canada) were interviewed. These interviews gathered information on mothers’ views about health and vaccination. Almost half of the mothers were categorized as vaccine-hesitant. A second interview was conducted with these mothers 3 to 11 months after birth to look at their actual decision and behavior concerning vaccination. Our results show the heterogeneity of factors influencing vaccine decision making. Although the majority of vaccine-hesitant mothers finally chose to follow the recommended vaccine schedule for their child, they were still ambivalent and they continued to question their decision.