UNITY Vision and Mission

1. AIM Adolescent Immunization Webinar: Adolescent Health Beliefs and Encouraging Provider Vaccination RecommendationsApril 25, 2017

2. UNITY Vision and Mission MISSION: Provide action-oriented leadership, innovation and education on preventive health and immunization for adolescents and young adults: DEVELOPhealthcare providers as advocates that make strong recommendations for all nationally recommended vaccines. ESTABLISHimmunization as a central component of preventative health and as an investment in lifelong health. VISION ENGAGEparents, adolescents and young adults to embrace the value of immunization. ENSUREeasy access to and timely delivery of all recommended vaccines. Coverage is 90% or greater for all nationally recommended vaccines for adolescents and young adults 1

3. Substantial Gaps In Adolescent VaccinationHPV (1st, Series), MenACWY Booster, and Flu 2015 Immunization Rates, United States 100 86 90 Healthy People 2020 Goal 81 80 70 60 63 Estimated vaccine coverage (%) 50 47 40 50 42 30 33 28 20 10 0 HPVd≥1 dose,females HPV • ≥1 dose, • males • HPV ≥3 doses,males • HPV ≥3 doses,females • Tdapa ≥1 dose • MenACWYb ≥1 dose MenACWY boosterc • Influenzae Vaccine a Tdap = tetanus, diphtheria, acellular pertussis; bMenACWY = meningococcal conjugate vaccine; cBooster-dose rate based on 17-year-olds; d HPV = human papillomavirus; e 2015-2016 influenza season MMWR. 2015;64(29):784-792; http://www.cdc.gov/flu/pdf/fluvaxview/2015-16/nfid-coverage-2015-16-final.pdf www.unity4teenvax.org

4. Recommended Immunizations11-12 Years and 16 Years Vaccine is recommended for all children unless your doctor tells you that your child cannot safely receive the vaccine Vaccine is recommended for children not at increased risk but who wish to get the vaccine after speaking to a provider Vaccine is recommended for children with certain health or lifestyle conditions that put them at an increased risk for serious diseases Vaccine should be given if a child is catching up on missed vaccines www.unity4teenvax.org https://www.cdc.gov/vaccines/who/teens/downloads/parent-version-schedule-7-18yrs.pdf

5. UNITY Members, Liaisons, and Participants www.unity4teenvax.org 2

6. Today’s Topics Beliefs on Adolescent Health and Immunization: Results From The Harris Poll of Teens, Parents and Healthcare Providers  Judy Klein, President, UNITY Consortium  Brief Discussion/Q&A Three Cs: Strong Provider Recommendations for Adolescent Vaccines Gregory Zimet, PhD, Professor of Pediatrics & Clinical Psychology, Indiana University School of Medicine Brief Discussion/Q&A www.unity4teenvax.org

7. Poll and Research Objectives • Unity-sponsored Harris poll with parents, teens and healthcare providers to understand their views on health, prevention and immunization. • Results used to educate and align parents, teens, and healthcare providers around the clear and certain value of immunization as a driver of adolescent and life long health

8. Topline U.S. Poll Results Methodology

9. Unity Survey U.S. Results Overview

10. Attitudes Towards Adolescent Preventive Health Staying healthy is very or extremely important to virtually all teens and their parents Teens are genuinely interested in living a healthy lifestyle and taking more responsibility for their health, more interested than HCPs and parents think More important General consensus between HCPs, parents and teens on what is important for teens staying healthy Keeping safe from STDs, avoiding alcohol/drugs/ smoking, getting enough sleep, eating healthy Getting all recommended vaccines, flu shots, seeing a doctor Less important

11. Adolescent Health – Roles and Responsibilities Teens believe… • Teens are more responsible than their parents for: • Exercising • Managing stress • Maintaining good oral health • Avoiding alcohol/drugs/smoking • Getting enough sleep • Keeping safe from STDs • Taking good care of skin • Parents are more responsible for: • Getting all recommended vaccines • Seeing a doctor regularly • Getting a flu shot

12. Health Today Vs. Future • Virtually all healthcare providers agree that many teens think things they do now will not have a big effect on their health in the future. • Sizeable minorities of teens and parents share this belief Things I do now will not have a big effect on my health in the future (% Strongly/Somewhat agree)

13. Responsibility for Maintaining Good Health • Nearly universally, doctors and teens believe that ultimately maintaining good health is the teens’ responsibility. • While still a majority, parents are less likely to place the full burden on teens. 94% teens 63% parents 98% HCPs Teens should be encouraged to assume more responsibility for their health I feel that my (son/daughter)'s health is his/her responsibility I feel like my health is my responsibility

14. Adolescent Health – Roles and Responsibilities • Almost all teens fully trust their HCPs for info about their health, but many don’t like talking to their HCPs and don’t visit HCPs if they feel healthy or see why they should • HCPs overwhelmingly agree that these misperceptions are common among teens

15. Adolescent Health – Roles and Responsibilities • The majority of HCPs, parents and teens agree that: • Teens need parents’ help to stay healthy • Teens and parents need to learn more about how to be healthy • Keeping teens healthy requires a coordinated/joint effort of parents, teens’ physicians and other HCPs • Parents are important to teens as it relates to their health • Most teens first turn to their parents for info about their health • Virtually all teens are comfortable asking and completely trust their parents on questions about their health • Only a minority of HCPs believe that teens are comfortable talking to parents about their health

16. Vaccination Roles and Responsibilities • Teens, parents and HCPs believe that parents are and should be primarily responsible for kids getting all recommended vaccines • Teens rely on doctors and parents for information about vaccines, with parents most influencing the decision on whether to receive a vaccine; friends have some influence as well • Teens are not interested in having more say • Parents rely on doctors as their primary source of information about specific vaccines • Physicians think that parents have the most influence on whether their teens, particularly younger teens ages 13-15, receive vaccinations

17. Vaccination Physicians report that ~1/5 teens are not up to date on their vax Less than 2/3 of physicians have processes to remind teen patients about the next recommended vaccine Less than 1/2 have reminders in place for the missed vaccination • Virtually all HCPs think teens and parents should better understand the benefits of vaccination • Virtually all HCPs say they take time to convince parents and teens to have teens vaccinated • Most HCPs think more materials are needed to help HCPs stay informed and to help HCPs discuss vaccinations with parents and teens

18. Relevance of Vaccines There is a sizeable minority Teens and Parents who don’t understand how vaccines help teens. And half or more share some concerns about safety. Teens believe… Parents believe… HCPs believe… 57% 47% 23% 34% 98% What I have read on social media has me concerned about the safety of some vaccines I have some concerns about the safety of vaccinations Vaccines are for babies, not as important for teens I don't know how being vaccinated helps me Teens and Parents should better understand the benefits of vaccination 57% 45% 23% 23%

19. Take-Aways and Implications for HCPs“Shared Responsibility for Life Long Health” Virtually all healthcare providers agree that many teens think the things they do now will not have a big effect on their health in the future. In reality, the habits adopted at a young age can have life-long effects. Diet, activity level, risky behavior choices, and a willingness to embrace preventive health, can all impact adolescents well into adulthood. Almost all teens fully trust their HCPs for information about their health, but they don’t necessarily see their doctor regularly enough to learn about their health, and when they do engage in conversations, it rarely goes beyond the typical teenage one word answers. Nearly all healthcare professionals believe teens should be encouraged to assume more responsibility for their health. Between trusting their doctor and teens reliance on their parents to stay healthy, a coordinated effort of parents, and HCPs can make the difference. Taking time now to discuss why the things we do now, like getting immunized, can have a life long-impact, can make a permanent difference in how these teens grow into adults and caregivers for future generations.

20. Messages for Healthcare Providers to Parents and Teens Healthcare providers should advocate to parents AND teens the reason why preventative health and vaccinations are critical for life long health > 90% of HCPs believe teens think the things they do now will not have a big effect on their health in the future Be blunt in the need for preventative health including vaccination. Address misperceptions and how avoidance can have long-term implications Vaccine safety concerns on social media still plague parents’ and teens’ perceptions. Reinforce the safety of and need for vaccines and the danger in skipping or delaying adolescent immunizations

21. Take-Aways and Implications for Parents/Teens“Shared Responsibility for Life Long Health” Parents and teenagers believe teens are genuinely interested in being healthy; with teen emphasis on general lifestyle goals like staying safe from STDs, good oral health, and avoiding drugs/alcohol. However, most teens are not interested in having more say in whether or not to get vaccinated. Maybe this is because ….they don’t understand why immunization is important or they have safety concerns based on what they read on social media. Regardless of the reason, if teens and parents aren’t taking the shared responsibility to learn preventative health habits, and to understand why vaccines are important, these teens are less likely to bring healthy habits into adulthood. Teens consistently look to their parents for advice. There is a widely recognized need for parents to stay involved in keeping their kids healthy so that they can lay the groundwork for a life long healthy lifestyle.

22. Messages for Parents to Teens Support teens in leading the way to vaccination, but also give them the information they need to understand why vaccinations are important 87% of parents say that they are more responsible for their teen getting all recommended vaccines Preventative health measures should become a habit. Let teens know why vaccines are important now and for their future Parents are not familiar with the vaccines recommended for teens Trust your healthcare provider and the experts - be in the know about the safety and benefit of vaccines and share that knowledge with your teen Many parents believe life is too busy to see the doctor when teens are healthy Find a convenient and trusted place for teens seeking general health information and guidance, including vaccines Parents pause when you hear health news that impacts teens (meningitis outbreaks) Take action to educate teens on what they can do to limit their risk

23. Discussion How can these Poll results support your efforts to increase vaccination coverage? www.unity4teenvax.org

24. Q & A www.unity4teenvax.org

25. Three CsObjectives • To review the Three Cs provider recommendation – confident, concise, and consistent – as a potential tool to improve routine vaccination coverage for adolescent vaccines • To provide a simple framework and tools for the use of a Three Cs recommendation including FAQs and Motivational Interviewing techniques www.unity4teenvax.org

26. Routine Recommendation of Adolescent Vaccines • 11/12 Years Old • 16 Years Old • Same day vaccination of: • Same day vaccination of: • Tdap • MenACWY • HPV • 1 of 2 • Flu • (in season) • MenACWY Booster • Men B* • Flu • (in season) • MenB-FHbp • 1 of 2 • MenB-4C • 1 of 2 • 6-12 mos • >1 mo • 6 mos • HPV • 2 of 2 • Men B • 2 of 2 Reflects new ACIP dosing guidelines for routine administration of HPV and MenB; *MenB-FHbp: Trumenba (Pfizer); MenB-4C: Bexsero (Novartis); For persons at increased risk for meningococcal disease and during serogroup B outbreaks, administer 3 doses of MenB-FHbp administered at 0, 1-2, and 6 months www.unity4teenvax.org

27. The Three Cs Approach Focuses On The In-Office, Provider Recommendation Followup Vaccination Discussion Vaccination Action Pre-Visit/ Visit Arrival Vaccination Recommendation • Knowledge/engagement/expectations • Parents • Adolescents • Providers • EHR prompts • Standing Orders • Provider recommendation • FAQs • Discussion aligned to parental disposition • Same visit administration vs. delay • Vaccine series completion • Reminder/recall • Preventive visits • Vaccination visits (series completion) Three Cs Recommendation Confident, Concise, Consistent (11, 12, 16 year olds’ visits) www.unity4teenvax.org

28. Three Cs ApproachConfident, Concise, Consistent Provider Recommendation Provider Tools • Presumptive • Bundled and Equal • Same Day Vaccination • FAQs • Motivational Interviewing www.unity4teenvax.org • UNITY Consortium

29. Delivering A Three Cs Recommendation ASSUME ‘acceptor’ status for all parents • DELIVER Three Cs Recommendation • Presumptive • Bundled and equal • Same day vaccination Consent? VACCINATE! www.unity4teenvax.org • Three Cs: Confident, Concise, Consistent

30. Anatomy Of A Three Cs RecommendationPresumptive Recommendation • HOW the recommendation is initiated • Assumes that parent will consent • Recommends with confidence and conviction • Presumptive Presumptive Language 11-12 year old visit: “Our sixth grade vaccines that we do, there are three… 11-12 year old visit: “He's due for his 11-year-old shots. We didn’t do them last time he was here for his check up because he was sick last time, but he is due for three vaccines. 16 year old visit: “Right now, today, we're talking about your vaccines, and you are due for the two meningitis shots” • Three Cs QI Study, 2016 www.unity4teenvax.org

31. Value of a Presumptive Recommendation • Multiple studies suggest that • a presumptive recommendation • leads to a • higher rate of vaccination Opel, D. et al, Pediatrics, 2013: 132:1–10; Brewer, N. et al, Pediatrics, Published online December 2016, 10.1542/peds.2016-1764 www.unity4teenvax.org

32. Anatomy Of A Three Cs RecommendationBundled, Equal Recommendation • HOW the recommendation is framed • Recommend all ACIP-recommended vaccines for that age (11/12, 16 years old) equally • Bundled, Equal Bundled and Equal Language • 11-12 year old visit: “Our sixth grade vaccines that we do, there are three, and it's the Tdap, which is tetanus, diphtheria, pertussis. The other one is Gardasil, or HPV, and that one protects against cancer, and then the third one is meningitis, and that is a brain infection that we want to prevent.” • 11-12 year old visit: “He is due for three vaccines. Actually we can do four today. So the three he's normally due for, he is due for meningitis, the HPV and the Tdap, and we can also do the flu vaccine today.” • 16 year old visit: “What you are due for today, I'm sure you're due for the two meningitis shots” • Three Cs QI Study, 2016 www.unity4teenvax.org

33. Anatomy Of A Three Cs RecommendationUnbundled, Unequal Language Unbundled and Unequal Language • “There are some required immunizations, and there is also a couple of immunizations we like to give just for general health and benefit” • “One is your tetanus vaccine that is required for school, and then the HPV vaccine. That is kind of important…And then the other one is the meningitis vaccine, which is not required for school here, but in many states it is a requirement for middle school. It is a really important vaccine. It's not something that you kind of ignore.” ✗ • Three Cs QI Study, 2016 www.unity4teenvax.org

34. Anatomy Of A Three Cs RecommendationSame Day Vaccination • Same Day Vaccination • HOW the recommendation is offered • Administer all recommended vaccines at this office visit Same Day Vaccination Language • “He is going to be entering seventh grade….So there are several shots thatwe give at this time.” • So he'll get the first dose today and comes back in x months for the second dose…” • “You will get one shot of each today.” • Offering Delay Can Lead to Non-Vaccination • “You obviously do not have to do all of them today.” • “It’s up to you. You can do them all now or you can wait.” www.unity4teenvax.org • Three Cs QI Study, 2016; UNITY

35. Three Cs Recommendations Today you are due for three shots –Tdap, HPV, and meningitis. These shots are all important because they protect you from serious diseases that could make you very sick. You will get one shot of each today. We will have you come back for the final HPV shot in 6 months. 11-12 YEARS Today you are due for two shots that can protect you from meningitis, a rare but serious brain infection. There are two different vaccines because they protect you from different types of meningitis infections. All meningitis can lead to serious illness or even death so I want to protect you from as many types as I can. The first vaccine is a single shot at this visit. With the second vaccine, you will get a first dose today and then we’ll schedule you to come back for one additional shot. 16 YEARS www.unity4teenvax.org • UNITY Consortium

36. Giving Confident and Concise Answers (FAQs) ASSUME ‘acceptor’ status for all parents • DELIVER Three Cs Recommendation • Presumptive • Bundled and equal • Same day vaccination FAQ Topics Urgency/Timing Safety Efficacy Shotphobia School Requirements Multiple Doses Cost Advice Tdap HPV Meningitis Consent? VACCINATE! Questions? CONVEY confident and concise answers www.unity4teenvax.org • Three Cs: Confident, Concise, Consistent

37. FAQ Resources • Three Cs Recommendation Language and FAQs • CDC FAQs (HPV) www.unity4teenvax.org/unity-projects www.cdc.gov/vaccines/who/teens/for-hcp-tipsheet-hpv.pdf www.unity4teenvax.org

38. FAQ Examples School Requirements Q. Which vaccines are required for school (or sports)? I think that I only want to only get those today. A. While there may be a subset of vaccines required for school entry, I recommend all of these vaccines based on expert recommendations from doctors and scientists and what is best for your health. I strongly recommend that you get all of the vaccines today. Urgency/Timing Safety Efficacy Shotphobia School Requirements Multiple Doses Cost Advice Tdap HPV Meningitis www.unity4teenvax.org • UNITY Consortium

39. Parental Disposition Framework Unquestioning Acceptor Vaccinate Three Cs Recommendation Three Cs Recommendation Answer Questions Vaccinate Cautious Acceptor Three Cs Recommendation Answer Questions Motivational Interviewing Reassess Vaccinate Hesitant Late or Selective Vaccinator Arrange Follow-Up Vaccinate Motivational Interviewing Reassess Refuser Arrange Follow-Up www.unity4teenvax.org Definitions of Parental Disposition from Leask, J. et al, BMC Pediatric 2012: 12:154, DOI: 10.1186/1471-2431-12-154; University of Colorado School of Public Health, Behavioral Health and Wellness Program

40. Parental DispositionMajority Of Parents Are “Acceptors” Leask, J. et al, BMC Pediatric 2012: 12:154, DOI: 10.1186/1471-2431-12-154

41. Parental Disposition Framework Unquestioning Acceptor Vaccinate Three Cs Recommendation Three Cs Recommendation Answer Questions Vaccinate Cautious Acceptor Three Cs Recommendation Answer Questions Motivational Interviewing Reassess Vaccinate Hesitant Late or Selective Vaccinator Arrange Follow-Up Vaccinate Motivational Interviewing Reassess Refuser Arrange Follow-Up www.unity4teenvax.org Definitions of Parental Disposition from Leask, J. et al, BMC Pediatric 2012: 12:154, DOI: 10.1186/1471-2431-12-154; University of Colorado School of Public Health, Behavioral Health and Wellness Program

42. Motivational Interviewing The Key To MI Is The Right “Heart” Set Partnership Active collaboration Acceptance Non-judgmental Compassion Focus on well-being Evocation Strengths and resources www.unity4teenvax.org University of Colorado School of Public Health, Behavioral Health and Wellness Program

43. Motivational InterviewingUsing OARS www.unity4teenvax.org University of Colorado School of Public Health, Behavioral Health and Wellness Program

44. Motivational InterviewingTools • Invite parent/adolescent (P/A) to talk about vax • Encourage discussion of the change (pros) • Elicithow the P/A thinks and feels about vax • Useempathic listening statements when P/A talks about vax • Acknowledgechallenges about vax that P/A faces • Provideinformation that is sensitive to P/A concerns • Actively convey respect for P/A choice • Exchange ideas with P/A about how to move forward toward acceptance www.unity4teenvax.org University of Colorado School of Public Health, Behavioral Health and Wellness Program

45. Motivational Interviewing What It Sounds Like Invites parent/adolescent to talk about vaccination What are your concerns about the vaccine?” How can I better help you to understand the value of vaccinating?” Encourages discussion of the change (pros) What benefits do you see in vaccinating? Why did you choose a 3 on the importance scale and not a lower number?” (when using scale) Elicits how the parent/adolescent thinks and feels about vax Tell me what you have heard about the side effects of the vaccine. What have you heard from the school? Uses empathic listening You are anxious because you’ve read some pretty scary stuff on the Internet. You’re worried about getting three shots at a time. Making the right decision is very important to you. www.unity4teenvax.org

46. Motivational Interviewing What It Sounds Like Acknowledges challenges I hear your concern about him being able to play softball tonight. Getting time off work to come in for the next HPV shot will be a challenge for you. Provides information that is sensitive to parent/adolescentconcerns You’ve mention two main concerns. Would it be alright with you if we talk about each one and then see what you think? Actively conveys respect for parent/adolescent choices I’ve shared my view about why this is an important vaccine but in the end this is a decision only you can make. Exchange ideas on how to move forward I have some information/ideas that might be helpful to you in making this decision. May I share them with you? www.unity4teenvax.org

47. Three Cs Recommendation Checklist11-12 Year and 16 Year Olds • Presumptive recommendation for ALL ACIP-recommended vaccines for the age-based visit • Vaccines presented in bundledand equal manner • Recommendation for same day vaccination • Accurateand concise responses to parental questions, if any • Identification of parent/adolescent disposition, particularly ‘cautious acceptor’ vs. ‘hesitant’ • Tailored conversation to parent/adolescent disposition • Motivational interviewing tools for ‘hesitant’ and ‘refusing’ parents/adolescents www.unity4teenvax.org • UNITY Consortium

48. Three Cs “Toolkit” • Three Cs Rationale • Three Cs Vignettes and Motivational Interviewing • 0.75 AMA PRA Category 1 Credits • Vignettes/MI Worksheet • Three Cs Recommendation Language and FAQs Parental Disposition and Motivational Interviewing for Hesitant or Refusing Parents Resources available at www.unity4teenvax.org/unity-projects

49. Summary • Providers are key to improving vaccination coverage for adolescents • A “strong” recommendation – confident, concise, and consistent (Three Cs) – can often lead to parental consent and same day vaccination • A Three Cs recommendation can be successful with the vast majority of parents • For those parents that are truly hesitant, providers can apply simple Motivational Interviewing tools to collaborate with parents and increase a parent’s motivation to change www.unity4teenvax.org

50. How To Support Three Cs ADOPTion! A • ssess current behaviors • etermine what changes to make initially, then sequence • bserve impact and reactions • ractice and routinize • each, train, and tell others D O P T www.unity4teenvax.org