AIM Adolescent Immunization Webinar: Adolescent Health Beliefs and Encouraging Provider - PowerPoint Presentation

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

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UNITY Vision and Mission

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ESTABLISH

immunization as a central component of preventative health and as an investment in lifelong health.

MISSION: Provide action-oriented leadership, innovation and education on preventive health and immunization for adolescents and young adults:

DEVELOP healthcare providers as advocates that make strong recommendations for all nationally recommended vaccines.

ENGAGE parents, adolescents and young adults to embrace the value of immunization.

ENSURE easy access to and timely delivery of all recommended vaccines.

Coverage is 90% or greater for all nationally recommended vaccines for adolescents and young adults

VISION

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Substantial Gaps In Adolescent VaccinationHPV (1st, Series), MenACWY Booster, and Flu

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a

Tdap = tetanus, diphtheria, acellular pertussis;

b

MenACWY = meningococcal conjugate vaccine; c Booster-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.pdf010

2030

4050

6070

80

90

100

Vaccine

MenACWY

b

≥

1 dose

MenACWY

booster

c

33

HPV

d

≥1 dose,

females

63

HPV

≥

3 doses,

females

42

HPV

≥

1 dose,

males

50

HPV

≥

3 doses,

males

28

2015

Immunization Rates, United States

Tdap

a

≥

1 dose

86

Estimated vaccine

coverage (%)

Healthy People 2020

Goal

Influenza

e

47

81

www.unity4teenvax.org

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Recommended Immunizations11-12 Years and 16 Years4

https

://www.cdc.gov/vaccines/who/teens/downloads/parent-version-schedule-7-18yrs.pdf

V

accine is recommended for all children unless your doctor tells you that your child cannot safely receive the vaccine

www.unity4teenvax.org

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 diseasesVaccine should be given if a child is catching up on missed vaccines

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UNITY Members, Liaisons, and Participants

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www.unity4teenvax.org

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Today’s Topics6

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&AThree Cs: Strong Provider Recommendations for Adolescent VaccinesGregory Zimet, PhD, Professor of Pediatrics & Clinical Psychology, Indiana University School of

MedicineBrief Discussion/Q&A

www.unity4teenvax.org

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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

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Topline U.S. Poll Results

Methodology

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Demographics

Teens

Gender:

Male

51%Female 49%Age:

13-15 54%16-18 46%Ethnicity:White

56%Hispanic22%Black10%African American

4%Asian or Pacific Islander4%Mixed racial background

2%Native American or Alaskan native1%Decline to Answer

1%ParentsGender:

Male44%Female56%

Age:

Under 3513%

35-5470%55+

17%Mean

45.2Ethnicity:

White

66%

Hispanic

17%

Black

8%

African American

3%

Asian or Pacific Islander

2%

Mixed racial background

1%

Decline

to answer

2%

Age/Gender of Child:

Male 13-15

24%

Male 16-18

24%

Female 13-15

27%

Female 16-18

26%

Physicians

Gender:

Male

57%

Female

43%

Mean age:

42.4

Mean # of patients see in typical month:

443

PCP

63%

PED

37%

Pharmacists

Gender:

Male

55%

Female45%

Mean age:49.9

SettingPharmacy chain

42%

Independent pharmacy30%Local grocery/food store14%Big-box/super center9%

Other5%

Base: All Teens (n=506)

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Unity Survey U.S. Results

Overview

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Attitudes Towards Adolescent Preventive Health

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Staying healthy

is very or extremely important to virtually

all teens and their parentsTeens are genuinely

interested in living a healthy lifestyle and taking more responsibility for their health, more interested than HCPs and parents thinkGeneral 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

More importantLess important

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Teens are more responsible than their parents for:

Exercising

Managing stress

Maintaining good oral healthAvoiding alcohol/drugs/smoking

Getting enough sleepKeeping safe from STDsTaking good care of skinAdolescent Health – Roles and ResponsibilitiesTeens believe…

Parents are more responsible for:Getting all recommended vaccinesSeeing a doctor regularlyGetting a flu shot

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Health Today Vs. Future

n=506

n=515

n=405

n=105

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)

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Responsibility for Maintaining Good Health

I feel like my health is my responsibility

94

%

teens

63

%parentsI feel that my (son/daughter)'s health is his/her responsibility98%HCPsTeens should be encouraged to assume more responsibility for their 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.

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Adolescent Health – Roles and ResponsibilitiesAlmost 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

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Adolescent Health – Roles and ResponsibilitiesThe 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 HCPsParents 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

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Vaccination Roles and Responsibilities

Teens, parents and HCPs believe

that

parents

are and should be

primarily responsible for kids getting all recommended vaccinesTeens 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 sayParents rely on doctors as their primary source of information about specific vaccinesPhysicians think that parents have the most influence on whether their teens, particularly younger teens ages 13-15, receive vaccinations

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Vaccination

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 vaccinationPhysicians report that ~1/5 teens are not up to date on their vax

Virtually all

HCPs think teens and parents should better understand the benefits of vaccinationVirtually 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

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Relevance of VaccinesTeens and Parents should

better understand the benefits of vaccination

98

%

I have some concerns about the safety of vaccinations57%57%

What I have read on social media has me concerned about the safety of some vaccines47%45%Vaccines are for babies, not as important for teens23%

23%I don't know how being vaccinated helps me34%23%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. HCPs believe…Teens believe…

Parents believe…

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Take-Aways and Implications for HCPs

“Shared

Responsibility for

Life Long Health”

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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.

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Messages for Healthcare Providers to Parents and Teens

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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

Vaccine safety concerns on social media still plague parents’ and teens’ perceptions.Be blunt in the need for preventative health including vaccination. Address misperceptions and how avoidance can have long-term implicationsReinforce the safety of and need for vaccines and the danger in skipping or delaying adolescent immunizations

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Take-Aways and Implications for Parents/Teens

“Shared

Responsibility for

Life Long Health”

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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.

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Messages for Parents to Teens

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Support

teens in leading the way

to vaccination,

but also give them the information they need to understand why vaccinations are important87% of parents say that they are more responsible for their teen getting all recommended vaccinesParents are not familiar with the vaccines recommended for teensParents pause

when you hear health news that impacts teens (meningitis outbreaks)Take action to educate teens on what they can do to limit their riskPreventative health measures should become a habit. Let teens know why vaccines are important now and for their futureTrust 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

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Discussion24

www.unity4teenvax.org

How can these

Poll

results

support your efforts to

increase vaccination coverage?

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Q & A

www.unity4teenvax.org

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Three CsObjectives26

To review the Three Cs provider recommendation

–

confident, concise, and consistent

–

as a potential tool to improve routine vaccination coverage for adolescent vaccinesTo provide a simple framework and tools for the use of a Three Cs recommendation including FAQs and Motivational Interviewing techniques

www.unity4teenvax.org

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Routine Recommendation of Adolescent Vaccines

11/12 Years Old

Same day vaccination of:

Tdap

MenACWY

HPV

1 of 2

HPV

2 of 2

Flu

(in season)

6-12 mos

16 Years Old

Same day vaccination of:

MenACWY Booster

Men B*

Men B

2 of 2

Flu

(in season)

6 mos

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

MenB-4C

1 of 2

MenB-

FHbp

1 of 2

>1 mo

www.unity4teenvax.org

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Pre-Visit/

Visit Arrival

Knowledge/engagement/expectations

Parents

AdolescentsProvidersEHR promptsStanding OrdersVaccination RecommendationThe Three Cs Approach Focuses On The In-Office, Provider Recommendation

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Vaccination Discussion

Vaccination Action

Followup

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

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29Three Cs Approach

Confident, Concise, Consistent

Provider Tools

Provider Recommendation

PresumptiveBundled and EqualSame Day Vaccination

FAQsMotivational Interviewing

UNITY Consortium

www.unity4teenvax.org

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Delivering A Three Cs Recommendation

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ASSUME ‘acceptor’ status for all parents

DELIVER Three Cs Recommendation

Presumptive

Bundled and equal

Same day vaccination Consent? VACCINATE!

Three Cs: Confident, Concise, Consistent

www.unity4teenvax.org

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Anatomy Of A Three Cs RecommendationPresumptive Recommendation31

Presumptive

HOW the recommendation is

initiated

Assumes

that parent will consentRecommends with confidence and conviction

Three Cs QI Study, 2016

www.unity4teenvax.org

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

”

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Value of a Presumptive Recommendation32

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

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Anatomy Of A Three Cs RecommendationBundled, Equal Recommendation33

Bundled, Equal

HOW the recommendation is

framed

Recommend all ACIP-recommended vaccines for that age (11/12, 16 years old) equally

Three Cs QI Study, 2016

www.unity4teenvax.org

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”

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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

Anatomy Of A Three Cs RecommendationUnbundled, Unequal Language

✗

www.unity4teenvax.org

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Anatomy Of A Three Cs RecommendationSame Day Vaccination35

Same Day Vaccination Language

“

He is going to be entering seventh grade

…

.So there are several shots that we 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.”

Same Day Vaccination

HOW the recommendation is offered

Administer all recommended vaccines at this office visit

Three Cs QI Study,

2016; UNITY

www.unity4teenvax.org

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

.”

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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. Three Cs Recommendations

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UNITY ConsortiumToday 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. 11-12 YEARS

16 YEARS

www.unity4teenvax.org

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Giving Confident and Concise Answers (FAQs)

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ASSUME ‘acceptor’ status for all parents

DELIVER Three Cs Recommendation

Presumptive

Bundled and equal

Same day vaccination Consent? VACCINATE! Questions?

CONVEY confident and concise answers

Three Cs: Confident, Concise, Consistent

FAQ Topics

Urgency

/Timing

SafetyEfficacyShotphobiaSchool RequirementsMultiple Doses

CostAdviceTdapHPVMeningitis

www.unity4teenvax.org

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FAQ Resources38

www.cdc.gov

/vaccines/who/teens/for-hcp-tipsheet-hpv.pdf

www.unity4teenvax.org/unity-

projects

www.unity4teenvax.orgThree Cs Recommendation Language and FAQs

CDC FAQs (HPV)

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FAQ Examples

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Urgency/Timing

Safety

Efficacy

ShotphobiaSchool RequirementsMultiple DosesCostAdviceTdapHPVMeningitis

UNITY Consortium

www.unity4teenvax.org

Urgency/Timing

Q. Can’t some of these shots wait until I am a little bit older?

A. It really is better to get them now. All three vaccines are recommended for your age and I want to protect you from these serious diseases now as well as keep you on schedule. Let’s do all three vaccines while you are here.Greg

– this is hidden. Can we delete?

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FAQ Examples

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Urgency/Timing

Safety

Efficacy

ShotphobiaSchool RequirementsMultiple DosesCostAdviceTdapHPVMeningitis

UNITY Consortium

www.unity4teenvax.org

Efficacy

Q. How long will the vaccines work? I don’t want to get them “too early” because they might wear off.A

. Vaccines are recommended at specific ages, taking into account when people are most likely to become exposed and the length of a vaccine’s protection. The vaccines I recommend are specifically recommended for your age; let’s get you protected today.Greg – this is hidden. Can we delete?

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FAQ Examples

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Urgency/Timing

Safety

Efficacy

ShotphobiaSchool RequirementsMultiple DosesCostAdviceTdapHPVMeningitis

UNITY Consortium

www.unity4teenvax.org

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.

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Parental Disposition Framework

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Unquestioning Acceptor

Cautious Acceptor

Hesitant

Late or Selective Vaccinator

RefuserVaccinate

Three Cs RecommendationAnswer Questions

VaccinateVaccinateVaccinate

ArrangeFollow-UpArrange

Follow-UpThree Cs RecommendationAnswer QuestionsMotivational Interviewing

Reassess

Motivational InterviewingReassess

Three Cs Recommendation

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

www.unity4teenvax.org

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Parental DispositionMajority Of Parents Are “Acceptors”Leask, J. et al, BMC Pediatric 2012:

12

:

154, DOI: 10.1186/1471-2431-12-154

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Parental Disposition Framework

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Unquestioning Acceptor

Cautious Acceptor

Vaccinate

Three Cs Recommendation

Answer Questions

VaccinateVaccinateVaccinate

ArrangeFollow-UpArrange Follow

-UpThree Cs RecommendationAnswer QuestionsMotivational Interviewing Reassess

Motivational InterviewingReassess

Refuser

HesitantLate or Selective Vaccinator

Three Cs Recommendation

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

www.unity4teenvax.org

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Motivational Interviewing45

Motivational interviewing is a

collaborative conversation style

for strengthening a person’s own motivation and commitment to change. It’s a way of being

versus a way of doing. For hesitant or refusing parents, providers can use motivational interviewing to interact in a way that increases the motivation to change and evokes change talk (a person’s own statements that favor change).

Example of change talk:“I value prevention and put great effort into keeping my kids healthy”University of Colorado School of Public Health, Behavioral Health and Wellness Program

www.unity4teenvax.orgGreg – this is hidden. Can we delete?

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Motivational Interviewing46

Partnership

Active collaborationAcceptance Non-judgmentalCompassion

Focus on well-beingEvocation Strengths and resourcesThe Key To MI IsThe Right “Heart” SetUniversity of Colorado School of Public Health, Behavioral Health and Wellness Program

www.unity4teenvax.org

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Motivational InterviewingUsing OARS47

University of Colorado School of Public Health,

Behavioral Health and Wellness Program

www.unity4teenvax.org

Slide48

Invite parent/adolescent (P/A) to talk

about vax

Encourage

discussion of the change (pros)Elicit

how the P/A thinks and feels about vaxUse empathic listening statements when P/A talks about vaxAcknowledge challenges about vax that P/A faces

Provide information that is sensitive to P/A concernsActively convey respect for P/A choiceExchange ideas with P/A about how to move forward toward acceptanceMotivational Interviewing

Tools

48University of Colorado School of Public Health, Behavioral Health and Wellness Program

www.unity4teenvax.org

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Motivational Interviewing What It Sounds Like49

www.unity4teenvax.org

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.

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Motivational Interviewing What It Sounds Like50

www.unity4teenvax.org

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/adolescent concernsYou’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?

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Three Cs Recommendation Checklist11-12 Year and 16 Year Olds

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Presumptive

recommendation for

ALL

ACIP-recommended vaccines for the age-based visit

Vaccines presented in bundled and equal manner

Recommendation for same day vaccinationAccurate and concise responses to

parental questions, if anyIdentification of parent/adolescent disposition, particularly ‘cautious acceptor’ vs. ‘hesitant’Tailored conversation to parent/adolescent disposition

Motivational interviewing tools for ‘hesitant’ and ‘refusing’ parents/adolescents

UNITY Consortium

www.unity4teenvax.org

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Three Cs “Toolkit”52

Resources available at www.unity4teenvax.org/unity-projects

Three

Cs

Rationale

Three Cs Vignettes and Motivational

Interviewing

0.75 AMA PRA Category 1 Credits

Three Cs Recommendation Language and FAQsParental Disposition and Motivational Interviewing for Hesitant or Refusing Parents

Vignettes/MI Worksheet

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Summary53

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 vaccinationA Three Cs recommendation can be successful with the vast majority of parentsFor 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

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How To Support Three Cs ADOPTion!54

ssess current behaviors

etermine what changes to make initially, then sequence

bserve impact and reactions ractice and routinize each, train, and tell others

A DOPT

www.unity4teenvax.org

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Discussion55

How can the Three Cs resources support your day-to-day activities?

How can UNITY support your stakeholders in their efforts to improve adolescent vaccination?

www.unity4teenvax.org

Slide56

56

Q & A

www.unity4teenvax.org

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

57