title: Experiences with provider and parental attitudes and practices regarding the administration of multiple injections during infant vaccination visits: lessons for vaccine introduction.
abstract: BACKGROUND
  An increasing proportion of childhood immunization visits include administration of multiple injections. Future introduction of vaccines to protect against multiple diseases will further increase the number of injections at routine immunization childhood visits, particularly in developing countries that are still scaling up introductions. Parental and healthcare provider attitudes toward multiple injections may affect acceptance of recommended vaccines, and understanding these attitudes may help to inform critical decisions about vaccine introduction.
  
  
  METHODS
  We conducted a systematic review of the literature to examine factors underlying reported parental and healthcare provider concerns and practices related to administration of multiple injections during childhood vaccination visits.
  
  
  RESULTS
  Forty-four articles were identified; 42 (95%) were from high income countries, including 27 (61%) from the USA. Providers and parents report concerns about multiple injections, which tend to increase with increasing numbers of injections. Common parental and provider concerns included apprehension about the pain experienced by the child, worry about potential side effects, and uncertainty about vaccine effectiveness. Multiple studies reported that a positive provider recommendation to the parent and a high level of concern about the severity of the target disease were significantly associated with parental acceptance of all injections. Providers often significantly overestimated parental concerns about multiple injections.
  
  
  CONCLUSIONS
  Providers may play a critical role in the decision for a child to receive all recommended injections. Their overestimation of parental concerns may lead them to postpone recommended vaccinations, which may result in extra visits and delayed vaccination. More research is needed on interventions to overcome provider and parental concern about multiple injections, particularly in developing countries.
authors.affiliation: Global Immunization Division, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS-A04, Atlanta, GA 30329, United States. Electronic address: awallace@cdc.gov.
authors.forename: Aaron S
authors.initials: AS
authors.lastname: Wallace
authors.affiliation: Immunizations, Vaccines and Biologicals Programme, World Health Organization, Geneva, Switzerland.
authors.forename: Carsten
authors.initials: C
authors.lastname: Mantel
authors.affiliation: Immunizations, Vaccines and Biologicals Programme, World Health Organization, Geneva, Switzerland.
authors.forename: Gill
authors.initials: G
authors.lastname: Mayers
authors.affiliation: United National Children's Fund, New York, NY, United States.
authors.forename: Osman
authors.initials: O
authors.lastname: Mansoor
authors.affiliation: Global Immunization Division, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS-A04, Atlanta, GA 30329, United States.
authors.forename: Jacqueline S
authors.initials: JS
authors.lastname: Gindler
authors.affiliation: Global Immunization Division, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS-A04, Atlanta, GA 30329, United States.
authors.forename: Terri B
authors.initials: TB
authors.lastname: Hyde
mesh_terms: D001291:Attitude of Health Personnel; D007722:Health Knowledge, Attitudes, Practice; D006282:Health Personnel / Q000523:psychology; D006801:Humans; D007115:Immunization Schedule; D007223:Infant; D007267:Injections / Q000009:adverse effects; D010290:Parents / Q000523:psychology*; D010342:Patient Acceptance of Health Care; D014611:Vaccination / Q000379:methods*
keywords: Measles; Multiple injections; Polio; Vaccination