Parent perspectives on childhood vaccination: How to deal with vaccine hesitancy and refusal?

Background

The aims of the study are to evaluate attitudes about childhood vaccines and vaccine refusal or delay among parents and to assess the role played by the variables mapped as potential determinants to suggest strategies that could improve childhood vaccination rates.

Mandatory infant & childhood immunization: Rationales,issues and knowledge gaps

Globally, infant and childhood vaccine uptake rates are not high enough to control vaccine preventable diseases, with outbreaks occurring even in high-income countries. This has led a number of high-, middle-and low income countries to enact, strengthen or contemplate mandatory infant and/or childhood immunization to try to address the gap. Mandatory immunization that reduces or eliminates individual choice is often controversial. There is no standard approach to mandatory immunization. What vaccines are included, age groups covered, program flexibility and rigidity e.g. opportunities for opting out, penalties or incentives, degree of enforcement, and whether a compensation program for causally associated serious adverse events following immunization exists vary widely. We present an overview of mandatory immunization with examples in two high- and one low-income countries to illustrate variations, summarize limited outcome data related to mandatory immunization, and suggest key elements to consider when contemplating mandatory infant and/or child immunization. Before moving forward with mandatory immunization, governments need to assure financial sustainability, uninterrupted supply and equitable access to all the population. Other interventions may be more effective and less intrusive than mandatory. If mandatory is implemented, this needs to be tailored to fit the context and the country’s culture.     

Health behaviors and utilization among users of complementary and alternative medicine for treatment versus health promotion

Objective. To compare the characteristics, health behaviors, and health services utilization of U.S. adults who use complementary and alternative medicine (CAM) to treat illness to those who use CAM for health promotion. Data Source. The 2007 National Health Interview Survey (NHIS). Study Design. We compared adult (age ≥18 years) NHIS respondents based on whether they used CAM in the prior year to treat an illness (n=973), for health promotion (n=3,281), or for both purposes (n=3,031). We used complex survey design methods to make national estimates and examine respondents' self‐reported health status, health behaviors, and conventional health services utilization. Principal Findings. Adults who used CAM for health promotion reported significantly better health status and healthier behaviors overall (higher rates of physical activity and lower rates of obesity) than those who used CAM as treatment. While CAM Users in general had higher rates of conventional health services utilization than those who did not use CAM; adults who used CAM as treatment consumed considerably more conventional health services than those who used it for health promotion. Conclusion. This study suggests that there are two distinct types of CAM User that must be considered in future health services research and policy decisions.     

Vaccine exemption requirements and parental vaccine attitudes: an online experiment

Increases in vaccine hesitancy and vaccine-preventable disease outbreaks have focused attention on state laws governing school-entry vaccine mandates and the allowable exemptions (medical and nonmedical) from those mandates. There is substantial variation in the type of exemptions available in each state, and states with more rigorous or burdensome exemption requirements generally have lower exemption rates. States have little evidence, however, about how vaccine-hesitant parents respond to different requirements. Despite recent efforts to formulate “model legislation” templates for states to follow, policy evidence about optimal exemption regimes is limited to observational studies in states that have changed exemption laws. We conducted two online experiments to explore how parental attitudes and intentions responded to different school-entry vaccine mandate exemption requirements. We randomly assigned online participants to one of four hypothetical vaccine exemption application scenarios: parental signature only, a checklist of vaccines for which an exemption is requested, a lengthy (10–30+ min) video-based vaccine education module, and a requirement to write a statement justifying the exemption. Among parents with high vaccine hesitancy, a required vaccine education module led to significant decreases in vaccine hesitancy, while checklist and justification requirements increased vaccine hesitancy slightly. Among parents with low vaccine hesitancy, we observed a potential backfire effect when parents were required to write a justification statement. Our findings warrant replication in a larger, fully-powered trial to accelerate knowledge about how parents across the vaccine hesitancy spectrum respond to exemption regimes.     

COVID-19 vaccine uptake before and after a vaccine mandate at a major academic hospital: Trends by race/ethnicity and level of patient contact

ObjectivesTo assess vaccine coverage rates before and after implementation of a COVID-19 vaccine mandate among Health care Personnel (HCP) and demographic characteristics associated with vaccine uptake Design, Setting, and Participants: Cohort study conducted among 10,889 hospital employees followed from Dec 16, 2020 - October 31, 2021, at a large academic hospital in Philadelphia. Main Outcome and Measures: Time to COVID-19 vaccination and vaccine series completion rates before and after implementation of a COVID-19 vaccine mandate based on age, gender, race/ethnicity, and level of patient contact/occupational group.ResultsThe vaccination series completion rate was 86.0% prior to mandate announcement, and increased to 98.7% after mandate implementation. Rates before mandate announcement were highest among Asians (96.2%), Whites (94.0%), males (89.7%), employees ≥ 65 years of age (95.2%), and employees with direct patient care (physicians, 99.0%, and nurses, 93.3%). Hospital educational initiatives (including Town Halls and discussions with Black and Hispanic employees with the lowest vaccination rates) appeared to improve uptake. The largest increase in series completion after mandate announcement occurred among Blacks, those of other/multiracial backgrounds, and Hispanics (35.6%, 22.4%, and 10.8%, respectively) as well as those with some or no direct patient contact (24.5% and 18.3%, respectively). Medical or religious exemptions were approved for 64 (<0.6%) employees and 38 (<0.4%) left their positions (8 voluntary, 30 involuntary) specifically due to the COVID-19 vaccine mandate. No clinically meaningful differences by age, gender, or race/ethnicity for those who were vaccinated under the mandate versus those who left their positions were noted.Conclusions and RelevanceThese results suggest that while mandates may be challenging to institutions and enforcement unpopular, they play an important role in reducing hesitancy and securing high vaccination rates among HCP, a group at high risk of COVID-19 given their employment and who can be a source of disease transmission to patients.     

The relationship between parental source of information and knowledge about measles / measles vaccine and vaccine hesitancy

ObjectivesBased on the hypothesis that sources of information might affect knowledge and vaccine acceptance, our objectives were to study parental characteristics and sources of information regarding measles/measles vaccine, its relationship to correct knowledge and to administration of the measles vaccine.BackgroundAlthough measles eradication is potentially achievable, in 2018–2019 a worldwide resurgence of measles and measles-caused deaths occurred. The main driver was incomplete or no vaccination, designated as vaccine hesitancy (VH).MethodsA cross-sectional survey of 399 individuals dispersed all over the country was conducted. Research assistants interviewed parents with a 20-question survey which was previously validated. The questionnaire included four sections: demographics, major sources of information on measles/measles vaccine, knowledge about measles/measles vaccine, and status of child’s vaccination. Univariate and multivariate analyses explored associations between correct knowledge and VH.ResultsThe majority of respondents were between the ages of 25–39 (62%). Of these, 309 (77%) vaccinated their children against measles on time, 32 (8%) vaccinations were incomplete, and 58 (15%) did not vaccinate, for a total VH of 23%. Parents < 30 years-old and those with a single-child vaccinated less frequently (p < 0.001 and p = 0.002, respectively). Internet and social-media were the major source of information for 32% regarding measles/measles vaccine and for 49% regarding the measles outbreak; both sources were negatively associated with correct knowledge (p < 0.001). In the multivariate analysis, knowledge was independently associated with timely vaccine administration (p < 0.001) and internet or social-media as sources with higher VH (OR 2.52, 95%CI 1.18–5.37 and OR 2.44, 95%CI 1.01–5.91, respectively).ConclusionsSocial-media and internet are a common source of information on measles/measles vaccine (probably on other vaccines as well), and often associated with incorrect knowledge, which relates significantly to VH. Healthcare professionals should be aware of this prevailing behavior and respond accordingly in these platforms, with the aid of experts in social-networking.     

Association of vaccine hesitancy and immunization coverage rates in the European Union

While previous studies have validated vaccine hesitancy scales with uptake behavior at the individual level, the conditions under which aggregated survey data are useful are less clear. We show that vaccine public opinion data aggregated at the subnational level can serve as a valid indicator of aggregate vaccine behaviour. We use a public opinion survey (Eurobarometer EB 91.2) with data on vaccine hesitancy for the EU in 2019. We link this information to (subnational) regional immunization coverage rates for childhood vaccines – DTP3, MCV1, and MCV2 -- obtained from the WHO for 2019. We conduct multilevel regression analyses with data for 177 regions in 20 countries. Given the variation in vaccine hesitancy and immunization rates between countries and within countries, we affirm the valuable role that surveys can play as a public health surveillance tool when it comes to vaccine behavior. We find statistically significantly lower regional vaccine immunization rates in regions where vaccine hesitancy is more pronounced. Our results suggest that different uptake rates across subnational regions are due, at least in part, to differences in attitudes towards vaccines and vaccination. The results are robust to several alternative specifications.     

Vaccine sentiments and under-vaccination: Attitudes and behaviour around Measles,Mumps, and Rubella vaccine (MMR) in an Australian cohort

ObjectiveThe study aimed to examine the consistency in factors associated with attitudes towards vaccination and MMR vaccination status.MethodsUsing the nationally representative Longitudinal Study of Australian Children matched with the Australian Childhood Immunisation Register, 4,779 children were included from 2004–2005 to 2010–11. Different MMR vaccine dosages and general attitude towards vaccination were modelled individually with multinomial logit regressions, controlling for demographic, socioeconomic, and health related factors of the children and their primary carers.ResultsThe group with non-vaccination and negative attitudes was characterised by more siblings and older parents; the group with under-vaccination but positive attitudes was characterised by younger parental age; and the group with under-vaccination and neutral attitudes was characterised by less socioeconomically advantaged areas. The presence of parental medical condition(s), being private or public renters, and higher parental education were associated with under-vaccination but not with attitudes towards vaccination, whilst parental religion was associated with attitudes towards vaccination but not reflected in the vaccine uptake.ConclusionsVaccine attitudes were largely consistent with MRR vaccine outcomes. However, there was variation in the associations of factors with vaccine attitudes and uptake. The results have implications for different policy designs that target subgroups with consistent or inconsistent vaccination attitudes and behaviour. Parents with intentional and unintentional under-vaccination are of policy concern and require different policy solutions.     

Measuring vaccine hesitancy,confidence, trust and flu vaccine uptake: Results of a national survey of White and African American adults

Introduction

Vaccine hesitancy (VH) has emerged as a factor in vaccine delay and refusal yet the measurement of the constructs within vaccine hesitancy remains a challenge. Outstanding questions include; should VH be measured as an attitude or a behavior? What is the role of key constructs including confidence, complacency, and convenience? What is the role of trust? Should measures be general or vaccine specific? Furthermore, much of the research has centered on parental acceptance of vaccines for their children.

The vaccine hesitancy scale: Psychometric properties and validation

IntroductionThe SAGE Working Group on Vaccine Hesitancy developed a vaccine hesitancy measure, the Vaccine Hesitancy Scale (VHS). This scale has the potential to aid in the advancement of research and immunization policy but has not yet been psychometrically evaluated.MethodsUsing a cross-sectional design, we collected self-reported survey data from a large national sample of Canadian parents from August to September 2016. An online questionnaire was completed in English or French. We used exploratory and confirmatory factor analysis to identify latent constructs underlying parents' responses to 10 VHS items (response scale 1–5, with higher scores indicating greater hesitancy). In addition to the VHS, measures included socio-demographics items, vaccine attitudes, parents’ human papillomavirus (HPV) vaccine decision-making stage, and vaccine refusal.ResultsA total of 3779 Canadian parents completed the survey in English (74.1%) or French (25.9%). Exploratory and confirmatory factor analysis revealed a two-factor structure best explained the data, consisting of ‘lack of confidence’ (M = 1.98, SD = 0.72) and ‘risks’ (M = 3.07, SD = 0.95). Significant Pearson correlations were found between the scales and related vaccine attitudes. ANOVA analyses found significant differences in the VHS sub-scales by parents’ vaccine decision-making stages (p < .001). Independent samples t-tests found that the VHS sub-scales were associated with HPV vaccine refusal and refusing another vaccine (p < .001). Socio-demographic differences in the VHS were found; however, effect sizes were small (η² < 0.02).ConclusionsThe VHS was found to have two factors that have construct and criterion validity in identifying vaccine hesitant parents. A limitation of the VHS was few items that loaded on the ‘risks’ component and a lack of positively and negatively worded items for both components. Based on these results, we suggest modifying the wording of some items and adding items on risk perceptions.     

Older adolescents and young adults willingness to receive the COVID-19 vaccine: Implications for informing public health strategies

ImportanceThe success in ending the COVID-19 pandemic rests partly on the mass uptake of the COVID-19 vaccine. Little work has been done to understand vaccine willingness among older adolescents and young adults. This is important since this age group may be less likely to adhere to public health guidelines.ObjectiveTo understand willingness of getting a vaccine and reasons for vaccine hesitancy among a sample of older adolescents and young adults.DesignData were from the Well-Being and Experiences study (The WE Study), a longitudinal community-based sample of older adolescents and young adults collected from Winnipeg, Manitoba, Canada from 2017 to 2020 (n = 664).SettingThe study setting was a community-based observational longitudinal study.ParticipantsParticipants for the study were aged 14 to 17 years old at baseline in 2016–17 (n = 1000). Data were also collected on one parent/caregiver. Waves 2 (n = 747) and 3 (n = 664) were collected in 2019 and 2020, respectively.ExposuresThe main exposures were sociodemographic factors, health conditions, COVID-19 knowledge, and adversity history.Main OutcomesThe main outcomes were COVID-19 vaccine willingness, hesitancy, and reasons for hesitancy.ResultsWillingness to get a COVID-19 vaccine was 65.4%. Willingness did not differ by age, sex, or mental health conditions, but did differ for other sociodemographic characteristics, physical health conditions, COVID-19 knowledge, practicing social/physical distancing, and adversity history. The most common reasons for not wanting a vaccine were related to safety, knowledge, and effectiveness. Sex differences were noted.Conclusions and RelevanceIncreasing uptake of the COVID-19 vaccine among older adolescents and young adults may rely on targeting individuals from households with lower income, financial burden, and adversity history, and generating public health messaging specifically aimed at vaccine safety, how it works to protect against illness, and why it is important to protect oneself against a COVID-19 infection.     

Addressing vaccine hesitancy: The potential value of commercial and social marketing principles and practices

Many countries and communities are dealing with groups and growing numbers of individuals who are delaying or refusing recommended vaccinations for themselves or their children. This has created a need for immunization programs to find approaches and strategies to address vaccine hesitancy. An important source of useful approaches and strategies is found in the frameworks, practices, and principles used by commercial and social marketers, many of which have been used by immunization programs. This review examines how social and commercial marketing principles and practices can be used to help address vaccine hesitancy. It provides an introduction to key marketing and social marketing concepts, identifies some of the major challenges to applying commercial and social marketing approaches to immunization programs, illustrates how immunization advocates and programs can use marketing and social marketing approaches to address vaccine hesitancy, and identifies some of the lessons that commercial and non-immunization sectors have learned that may have relevance for immunization. While the use of commercial and social marketing practices and principles does not guarantee success, the evidence, lessons learned, and applications to date indicate that they have considerable value in fostering vaccine acceptance.     

Vaccine decision-making begins in pregnancy: Correlation between vaccine concerns,intentions and maternal vaccination with subsequent childhood vaccine uptake

IntroductionMaternal and childhood vaccine decision-making begins prenatally. Amongst pregnant Australian women we aimed to ascertain vaccine information received, maternal immunisation uptake and attitudes and concerns regarding childhood vaccination. We also aimed to determine any correlation between a) intentions and concerns regarding childhood vaccination, (b) concerns about pregnancy vaccination, (c) socioeconomic status (SES) and (d) uptake of influenza and pertussis vaccines during pregnancy and routine vaccines during childhood.MethodsWomen attending public antenatal clinics were recruited in three Australian states. Surveys were completed on iPads. Follow-up phone surveys were done three to six months post delivery, and infant vaccination status obtained via the Australian Childhood Immunisation Register (ACIR).ResultsBetween October 2015 and March 2016, 975 (82%) of 1184 mothers consented and 406 (42%) agreed to a follow up survey, post delivery. First-time mothers (445; 49%) had significantly more vaccine concerns in pregnancy and only 73% had made a decision about childhood vaccination compared to 89% of mothers with existing children (p-value < 0.001). 66% of mothers reported receiving enough information during pregnancy on childhood vaccination. In the post delivery survey, 46% and 82% of mothers reported receiving pregnancy influenza and pertussis vaccines respectively. The mother's degree of vaccine hesitancy and two attitudinal factors were correlated with vaccine uptake post delivery. There was no association between reported maternal vaccine uptake or SES and childhood vaccine uptake.ConclusionFirst time mothers are more vaccine hesitant and undecided about childhood vaccination, and only two thirds of all mothers believed they received enough information during pregnancy. New interventions to improve both education and communication on childhood and maternal vaccines, delivered by midwives and obstetricians in the Australian public hospital system, may reduce vaccine hesitancy for all mothers in pregnancy and post delivery, particularly first-time mothers.     

An assessment of parental knowledge,attitudes, and beliefs regarding influenza vaccination

IntroductionSeasonal influenza imposes a significant clinical and economic burden. Despite the availability of an annual vaccine to prevent influenza infection and reduce disease severity, influenza vaccination rates remain suboptimal. Research suggests personal experience, perceived effectiveness, and concerns regarding vaccine safety and side effects are the most influential factors in predicting a parent’s decision to vaccinate. However, current literature is primarily focused on the vaccine decision-making of healthcare workers and those at high risk for influenza complications.MethodsTo assess parental attitudes and beliefs regarding the influenza vaccine, a brief mixed-methods survey was developed and optimized for an electronic platform. The Health Belief Model informed survey design and data analysis. Questions were classified into five core concepts: knowledge, barriers, benefits, experience, and severity. Participants were solicited from a population of parents whose children had participated in a school-based influenza surveillance study (n = 244, 73% response rate). We tested associations between responses and children’s influenza vaccination status the prior season. Categorical questions were tested using Pearson's chi-squared tests and numerical or ordered questions using Mann-Whitney tests. P-values were corrected using the Bonferroni method.ResultsDoubting effectiveness, concerns about side effects, inconvenience, and believing the vaccine is unnecessary were barriers negatively associated with parents’ decision to vaccinate their children during the 2017–18 flu season (p < 0.001). Knowledge that the vaccine is effective in lowering risk, duration, and severity of influenza; receiving the influenza vaccine as an adult; and recognizing the importance of vaccination to prevent influenza transmission in high-risk populations were positively associated with parents’ decision to vaccinate (p < 0.001).ConclusionUnderstanding barriers and motivators behind parents’ decision to vaccinate provides valuable insight that has the potential to shape vaccine messaging, recommendations, and policy. The motivation to vaccinate to prevent influenza transmission in high-risk populations is a novel finding that warrants further investigation.     

Older adults' vaccine hesitancy: Psychosocial factors associated with influenza,pneumococcal, and shingles vaccine uptake

Influenza, pneumococcal disease, and shingles (herpes zoster) are more prevalent in older people. These illnesses are preventable via vaccination, but uptake is low and decreasing. Little research has focused on understanding the psychosocial reasons behind older adults’ hesitancy towards different vaccines. A cross-sectional survey with 372 UK-based adults aged 65–92 years (M = 70.5) assessed awareness and uptake of the influenza, pneumococcal, and shingles vaccines. Participants provided health and socio-demographic data and completed two scales measuring the psychosocial factors associated with vaccination behaviour. Self-reported daily functioning, cognitive difficulties, and social support were also assessed. Participants were additionally given the opportunity to provide free text responses outlining up to three main reasons for their vaccination decisions. We found that considerably more participants had received the influenza vaccine in the last 12 months (83.6%), relative to having ever received the pneumococcal (60.2%) and shingles vaccines (58.9%). Participants were more aware of their eligibility for the influenza vaccine, and were more likely to have been offered it. Multivariate logistic regression analyses showed that a lower sense of collective responsibility independently predicted lack of uptake of all three vaccines. Greater calculation of disease and vaccination risk, and preference for natural immunity, also predicted not getting the influenza vaccine. For both the pneumococcal and shingles vaccines, concerns about profiteering further predicted lack of uptake. Analysis of the qualitative responses highlighted that participants vaccinated to protect their own health and that of others. Our findings suggest that interventions targeted towards older adults would benefit from being vaccine-specific and that they should emphasise disease risks and vaccine benefits for the individual, as well as the benefits of vaccination for the wider community. These findings can help inform intervention development aimed at increasing vaccination uptake in future.     

Moderating effects of age,gender and education on the associations of perceived neighborhood environment attributes with accelerometer-based physical activity: The IPEN adult study

The study's purpose was to examine age, gender, and education as potential moderators of the associations of perceived neighborhood environment variables with accelerometer-based moderate-to-vigorous physical activity (MVPA). Data were from 7273 adults from 16 sites (11 countries) that were part of a coordinated multi-country cross-sectional study. Age moderated the associations of perceived crime safety, and perceiving no major physical barriers to walking, with MVPA: positive associations were only found in older adults. Perceived land use mix-access was linearly (positive) associated with MVPA in men, and curvilinearly in women. Perceived crime safety was related to MVPA only in women. No moderating relationships were found for education. Overall the associations of adults' perceptions of environmental attributes with MVPA were largely independent of the socio-demographic factors examined. These findings are encouraging, suggesting that efforts to optimize the perceived built and social environment may act in a socially-equitable manner to facilitate MVPA.     

A cross-sectional analysis of the association between social capital and willingness to get COVID-19 vaccine in Ontario,Canada

ObjectiveWe examine the role of social capital in intention to take the vaccine at the end of the first wave of the COVID-19 pandemic.MethodsThis study uses observational, cross-sectional data from the Ontario sample of the fall 2020 Canadian Community Health Survey (CCHS), a representative sample of the population with added questions relative to symptoms of COVID-19 and intentions to get vaccinated. Questions on social capital were asked to respondents from Ontario only, yielding a sample of 6516. Odds ratios (OR) and marginal effects at sample mean of an index of social capital (at the individual or aggregated level) on changes in intentions to get vaccinated are estimated from logistic regression models.ResultsIndividual-level social capital is associated with greater willingness to get vaccinated against COVID-19 (OR 1.09). Associations with aggregated-level social capital are less precisely estimated. Associations are the same for both males and females but vary across age categories: individual-level social capital is associated with higher willingness to get vaccinated among working-age respondents, but aggregate-level social capital is associated with higher willingness to get vaccinated among older adults.ConclusionVaccine hesitancy is not a random phenomenon, nor is it explained by individual characteristics such as education or income only. It also reflects the state of the social environment in which individuals live and public health messaging should take this into account if it is to be successful.Supplementary InformationThe online version contains supplementary material available at 10.17269/s41997-023-00746-9.     

The mediating effect of health literacy on COVID-19 vaccine confidence among a diverse sample of urban adults in Boston and Chicago

BackgroundA high rate of COVID-19 vaccination is critical to reduce morbidity and mortality related to infection and to control the COVID-19 pandemic. Understanding the factors that influence vaccine confidence can inform policies and programs aimed at vaccine promotion. We examined the impact of health literacy on COVID-19 vaccine confidence among a diverse sample of adults living in two major metropolitan areas.MethodsQuestionnaire data from adults participating in an observational study conducted in Boston and Chicago from September 2018 through March 2021 were examined using path analyses to determine whether health literacy mediates the relationship between demographic variables and vaccine confidence, as measured by an adapted Vaccine Confidence Index (aVCI).ResultsParticipants (N = 273) were on average 49 years old, 63 % female, 4 % non-Hispanic Asian, 25 % Hispanic, 30 % non-Hispanic white, and 40 % non-Hispanic Black. Using non-Hispanic white and other race as the reference category, Black race and Hispanic ethnicity were associated with lower aVCI (−0.76, 95 % CI −1.00 to −0.50; −0.52, 95 % CI −0.80 to −0.27, total effects from a model excluding other covariates). Lower education was also associated with lower aVCI (using college or more as the reference, −0.73 for 12th grade or less, 95 % CI −0.93 to −0.47; −0.73 for some college/associate's/technical degree, 95 % CI −1.05 to −0.39). Health literacy partially mediated these effects for Black and Hispanic participants and those with lower education (indirect effects −0.19 and −0.19 for Black race and Hispanic ethnicity; 0.27 for 12th grade or less; −0.15 for some college/associate's/technical degree).ConclusionsLower levels of education, Black race, and Hispanic ethnicity were associated with lower scores on health literacy, which in turn were associated with lower vaccine confidence. Our findings suggest that efforts to improve health literacy may improve vaccine confidence, which in turn may improve vaccination rates and vaccine equity.Clinical Trials Number: NCT03584490.     

公费医疗人群医改前后卫生服务需求比较

医改实施后,公费医疗人群的卫生服务需求发生了明显的变化。（1）择医行为：感到身体不适到医院就诊的频率有所下降,不按医生要求提前出院的频率上升,就诊流向基层医院;（2）择医行为：家中存药“有不少”的频率下降,主要购药途径为“到药店买药”的频率上升;（3）选择大型设备检查行为;就医时遵照医生要求做大型设备检查的频率下降,从宏观管理角度分析,这种行为选择趋势有利于卫生资源的合理有效利用,有利于控制医疗费用的过快增长,有利于实现社会保障的公平性。