Awareness, attitudes, and practices on meningococcal serogroup B vaccination in the United States among parents of older adolescents and among young adults

Abstract

Objective

Meningococcal serogroup B (MenB) vaccination is recommended by the Advisory Committee on Immunization Practices (ACIP) for adolescents and young adults 16–23-years-old under shared clinical decision-making (SCDM). However, MenB vaccination coverage in this population remains low in the United States (US). We investigated the awareness, attitudes, and practices regarding MenB disease and vaccination among parents of 16–18-year-old older adolescents and among 19–23-year-old young adults.

Methods

An online survey was conducted in September–October 2022 among parents of older adolescents and among young adults recruited from a US-based patient panel.

Results

There were 606 total participants, including parents of MenB-vaccinated (n = 151) and non-vaccinated (n = 154) adolescents, and also MenB-vaccinated (n = 150) and non-vaccinated (n = 151) young adults. Non-vaccinated cohorts reported low awareness of MenB disease (58.3–67.5%) and vaccination (49.7–61.0%), though awareness was higher among non-vaccinated parents. However, all cohorts reported high interest in learning more about MenB disease and vaccination. Vaccinated cohorts relied on primary care providers (PCPs) to initiate MenB vaccination conversation and had a low awareness of SCDM at 35.1–45.3%, though those aware of SCDM were more likely to participate in decision-making. Barriers to MenB vaccination included lack of PCP recommendation, vaccine side effects, and uncertainty about vaccination need.

Conclusions

There are gaps in awareness of MenB disease, vaccination, and SCDM among parents and patients in the US, resulting in missed opportunities for discussing and administering MenB vaccination. Targeted education on MenB and vaccination recommendations may increase these opportunities and improve MenB vaccination awareness and initiation.

PLAIN LANGUAGE SUMMARY

MenB disease, a type of meningitis, is a serious and life-threatening illness. The US Centers for Disease Control and Prevention (CDC) recommends that 16–23-year-olds get a MenB vaccine after talking with their healthcare provider and deciding it is the right choice. As of 2021, only about 3 in 10 17-year-olds had received a MenB vaccine. In this study, we used an online survey to learn about parents of older teens’ (16–18-years-old) and young adults’ (19–23-years-old) awareness, thoughts, and practices related to meningitis and the MenB vaccine. Parents of non-vaccinated teens, and non-vaccinated young adults, had a lower awareness of the causes, risks, and symptoms of meningitis, and the MenB vaccine. In addition, most parents thought the impact of meningitis would be severe, compared with young adults who thought it would be less severe. Most participants were also not aware of their role in deciding if they or their child should be vaccinated against MenB. However, most showed a high interest in learning more about meningitis and the MenB vaccine. We also found that most teens and young adults who did receive the MenB vaccine received it right after talking about it with their healthcare provider. These findings show a clear opportunity to address gaps in awareness and thoughts about meningitis and MenB vaccination. Providing education and resources to parents, young adults, and healthcare providers could create more opportunities to discuss MenB vaccination and lead to more teens and young adults accessing vaccination and being protected against meningitis.

Keywords:

• MenB
• MenB vaccination
• meningitis
• meningococcal disease
• adolescent
• young adult
• shared clinical decision-making

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Awareness, attitudes, and practices regarding meningococcal serogroup B vaccination in the United States among parents of older adolescents and among young adults: a plain language summary

Introduction

Invasive meningococcal disease (IMD), caused by Neisseria meningitidis, is a life-threatening illness that can worsen rapidly, with a 10–15% mortality rate even with appropriate treatment.¹ Up to 40% of IMD survivors may experience both short- and long-term sequelae, such as neurological problems, hearing loss, skin scarring, and amputation.² IMD is primarily spread by close personal contact, and living in crowded conditions and/or having a weak immune system can increase the risk of infection.^3,4 In 2019 (latest data unaffected by coronavirus disease 2019 [COVID-19] pandemic measures), the rate of IMD per 100,000 people was 0.11 in the general United States (US) population and 0.13 among adolescents 16–23-years-old.⁵ Among US 16–23-year-olds, meningococcal serogroup B (MenB) is the leading cause of IMD.^5–9

Upon US Food and Drug Administration (FDA) approval of MenB vaccines, the US Advisory Committee on Immunization Practices (ACIP) recommended MenB vaccination for adolescents and young adults 16–23-years-old under individual clinical decision-making (Category B).¹⁰ In 2019, this language was revised to shared clinical decision-making (SCDM).¹¹ SCDM refers to an individually-based vaccine recommendation, informed by a shared decision-making process between healthcare providers and patients and/or caregivers.¹¹ In the US, two brands of the MenB vaccine are approved for adolescents and recommended under SCDM.¹² As of 2022, adolescent MenB vaccination coverage remained low: only 29.4% of 17-year-olds had received ≥1 dose of the MenB vaccine, compared with 60.8% coverage for the routinely recommended serogroup A, C, W, and Y (MenACWY) vaccination booster.¹³ Even among 16–23-year-olds who had received ≥1 dose of the MenB vaccine, only 56.7% and 44.7% of Commercial and Medicaid populations completed the series of ≥2 doses, respectively, from January 2017 to September 2018.¹⁴

While the routine health care visit at age 16 provides an important opportunity for older adolescents to receive their recommended vaccines, lack of awareness of MenB disease and vaccination among parents and patients, as well as inconsistent provider implementation of SCDM, could be limiting opportunities for MenB protection via vaccination.^15,16 Furthermore, a recent survey found that most MenB vaccination conversations are initiated by physicians, which could indicate low parent and patient awareness of their roles in SCDM.¹⁵ Therefore, it is critical to understand the awareness and expectations of both parents of older adolescents and young adults regarding IMD and vaccination.

While some previous studies have captured patient-centric insights on IMD, all surveys were conducted prior to the 2019 recommendation update to SCDM.^17,18 We aimed to understand awareness, attitudes, and practices regarding MenB disease and vaccination among parents of older adolescents 16–18-years-old and among young adults 19–23-years-old in the US following the 2019 recommendation update. This study’s findings can be used to inform both patient-centric interventions to increase opportunities to discuss vaccination and improve medical strategies for implementing SCDM effectively and consistently for MenB vaccination.

Methods

Study design and population

This was a US-based observational, cross-sectional, double-blinded, and confidential study. An anonymous self-administered online survey was designed and conducted to capture the awareness, attitudes, and practices of parents of older adolescents and of young adults regarding IMD and vaccination.

Study participants were (a) parents of older adolescents 16–18-years-old and (b) young adults 19–23-years-old living in the US at the time of the survey. In this study, the term “parents” alone will also be used to refer to “parents of older adolescents 16–18-years-old”. The rationale for including parents rather than directly surveying older adolescents 16–18-years-old was state variability in parental consent for vaccination requirements and the key role of parents as vaccination decision-makers.

Participants were also split into cohorts by MenB vaccination status. “Vaccinated” participants were parents of adolescents who had received ≥1 dose of the MenB vaccine, and young adults who had received ≥1 dose of the MenB vaccine, in the past year. “Non-vaccinated” participants were parents of adolescents who had not received any MenB vaccine, and young adults who had not received any MenB vaccine.

A minimum of 300 parents and 300 young adults were sought during recruitment and screened for study inclusion until ≥150 eligible vaccinated and ≥150 eligible non-vaccinated individuals in both the parent and young adult cohorts completed the survey. Parents were included if they met the following eligibility criteria: being the parent/guardian of ≥1 adolescent 16–18-years-old at survey completion; being ≥24-years-old; responsible for arranging and having attended ≥50% of visits to primary care providers (PCPs) in the past three years for ≥1 qualified adolescent; their adolescent had ≥1 in-person PCP visit in the last year; and (for vaccinated adolescents) their adolescent had received the first dose of the MenB vaccine, in the presence of the parent, within the last year. Parents with employment-related conflicts of interest (e.g. FDA or drug manufacturer employment) were not included. In this study, the term “PCP” is used as parents and patients are more accustomed to this term than “healthcare provider”.

Young adults were included if they were 19–23-years-old at survey completion; had ≥1 in-person PCP visit in the last year; and (for vaccinated young adults) had received the first dose of the MenB vaccine within the last year. Young adults that were parents/guardians of a 16–18-year-old and/or those with employment-related conflicts of interest were not included.

The study protocol and preliminary questionnaire were submitted for Institutional Review Board (IRB) approval to WCG IRB prior to the survey test phase and fieldwork, and IRB exemption status was granted on 19 August 2022.

Survey and data collection

The survey was self-administered online between 20 September 2022 and 6 October 2022 (full survey available in Appendix A, supplementary material). The survey questionnaire was designed based on the study objectives and tailored to either parents or young adults. The Confirmit Horizons survey platform was used to host the survey, and surveys were pre-tested prior to data collection using web-assisted telephone interviews with 8 participants (2 participants per cohort; all excluded from the final sample).

The survey consisted of 67 closed (multiple-choice and Likert scale) and 2 open-ended questions. The survey included a screener section to record informed consent followed by five sections to record (1) participants’ relationship with their PCP, (2) general IMD and vaccine information, (3) experience with MenB vaccination, (4) reasons for not vaccinating against IMD, and (5) participant demographics. For ease of understanding for respondents, the survey used the term “meningitis” to refer to IMD. A brief definition of “meningitis” was provided at the beginning of the survey. Parents with more than one adolescent 16–18-years-old were asked to answer the questions relative to the adolescent with the nearest upcoming birthday only. All respondents were required to complete all survey questions assigned to their respective cohort; therefore, missing data was not present.

Data analysis

All variables were reported descriptively, for both parent of adolescent and for young adult cohorts. Descriptive statistics were also reported for vaccinated and non-vaccinated sub-cohorts, respectively. These included proportions for categorical variables (n, %) and the mean, standard deviation (SD), median, and minimum and maximum number for continuous variables, collectively providing an interpretation of the distributional characteristics of the data.

Four logistic regression models were run to identify the factors associated with (1) parent-reported MenB vaccination initiation among older adolescents, (2) self-reported MenB vaccination initiation among young adults, (3), proactive health-seeking behaviors (i.e. initiating the MenB vaccination discussion), and (4) PCPs’ explicit MenB recommendation. Model covariates that included select variables from the survey results (variables with clinical or practical relevance identified by the study team) were initially included in the regression models. Final covariates are described in the results section and mapped to their corresponding survey questions in Table S1 (supplementary material).

To better understand trends for key variables surrounding MenB vaccination, cross tables were generated to analyze differences driven by (1) PCP type on vaccination conversation initiator, (2) duration of relationship with PCP on vaccination recommendation type, (3) SCDM awareness on sharing in vaccination decision-making, and (4) duration of vaccination conversation on vaccination initiation.

Results

Participants

Demographic characteristics

In total, 305 parents of adolescents (151 vaccinated; 154 non-vaccinated) and 301 young adults (150 vaccinated; 151 non-vaccinated) completed the survey. Full demographic information of adolescents (as reported by parents) and young adults can be found in Table S2 (supplementary material).

Among vaccinated adolescents (n = 151), the mean (SD) age was 16.7 (0.6) years, and the majority were female (n = 83; 55.0%) and White or Caucasian (n = 109; 72.2%). Among this cohort, 45 (29.8%) resided in the South, 62 (41.1%) were living in a suburban area, 93 (61.6%) were attending high school at the time of the survey (most other adolescents were full- or part-time students in community college, technical or vocational schools, college, or university). In addition, 101 (66.9%) had commercial insurance, 47 (31.1%) were on Medicaid, and no vaccinated adolescents were uninsured.

The mean (SD) age of non-vaccinated adolescents (n = 154) was 16.6 (0.6) years, and respondents were primarily male (n = 87; 56.5%) and White/Caucasian (n = 106; 68.8%). Among this cohort, 62 (40.3%) resided in the South, 76 (49.4%) lived in a suburban area, and 82 (53.2%) were in high school (most other adolescents were full- or part-time students in community college, technical/vocational schools, college, or university). Among non-vaccinated adolescents, 100 (64.9%) had commercial insurance, 45 (29.2%) were on Medicaid, and 2 (1.3%) were uninsured.

Meanwhile, among vaccinated young adults (n = 150), the mean age was 21.2 (1.4) years, and respondents were predominantly female (n = 117; 78.0%) and White/Caucasian (n = 94; 62.7%). Among this cohort, 57 (38.0%) respondents resided in the South and 80 (53.3%) lived in a suburban area; 85 (56.7%) of respondents had commercial insurance, while 43 (28.7%) were on Medicaid and 3 (2.0%) were uninsured.

Non-vaccinated young adults (n = 151) were aged 21.3 (1.3) years on average, 100 (66.2%) were female, and 83 (55.0%) were White/Caucasian. In this cohort, 72 (47.7%) were from the South and 65 (43.0%) lived in a suburban area; 63 (41.7%) had commercial insurance, compared with 44 (29.1%) who were on Medicaid and 12 (7.9%) who were uninsured.

Information on primary care

Information on older adolescents’ primary care (as reported by parents) and young adults, including PCP visit frequency and length of time seeing current PCP, was collected (Table S3, supplementary material).

Among both vaccinated and non-vaccinated adolescents, a large majority (n = 146 [96.7%] and n = 143 [92.9%], respectively) reported visiting their PCP at least once per year for a routine visit. The largest proportion of vaccinated adolescents had been seeing their current PCP for >10 years (n = 66; 43.7%), compared with 3–10 years among non-vaccinated adolescents (n = 74; 48.1%). Meanwhile, among young adults, 130 (86.7%) vaccinated and 124 (82.1%) non-vaccinated young adults reported visiting their PCP at least once per year for a routine visit. Approximately half of both vaccinated and non-vaccinated young adults (n = 74 [49.3%] and n = 68 [45.0%], respectively) had been seeing their current PCP for 1–2 years.

Other vaccination status

Participants also reported their vaccination status for other common vaccines, including those against MenACWY; influenza; tetanus, diphtheria, and pertussis (Tdap); human papillomavirus (HPV); and COVID-19 (Table S4, supplementary material).

Less than half of the 154 non-vaccinated adolescents (for MenB) were vaccinated against MenACWY (n = 16; 10.4%), Tdap (n = 63; 40.9%), and HPV (n = 51; 33.1%), though the majority in this cohort were vaccinated against COVID-19 (n = 105; 68.2%) and influenza/flu (n = 84; 54.5%). Less than half of the 151 non-vaccinated young adults (for MenB) were vaccinated against MenACWY (n = 10; 6.6%), HPV (n = 19; 12.6%), Tdap (n = 23; 15.2%), and influenza/flu (n = 70; 46.4%), though 88 (58.3%) were vaccinated against COVID-19. In contrast, the majority of both MenB-vaccinated adolescents and MenB-vaccinated young adults were vaccinated against all of these diseases.

Hereinafter, results are presented in the order of the primary objective (PO1), secondary objectives (SO1–6), and exploratory objectives (EO1–3). Study objectives are defined in Table 1.

Table 1. Study objectives.

Primary objective	Secondary objectives	Exploratory objective
To evaluate US parents’ of older adolescents and young adults’: PO1: Awareness of IMD and vaccination	To evaluate US parents’ of older adolescents and young adults’: SO1: Attitudes related to IMD and vaccination SO2: Practices regarding IMD-related health-seeking behaviors, use of approaches and/or resources to inform decision-making about receiving or not receiving the MenB vaccine series, and self-reported receipt of the MenB vaccine series SO3: Expectations of primary care providers (PCPs)^a during healthcare visits (regarding MenB vaccination recommendation) SO4: Preferences regarding PCP implementation of SCDM SO5: Perceptions regarding the level of effort made by PCPs to provide information on MenB vaccination SO6: Barriers to and decision drivers of MenB vaccine series initiation and completion	EO1: To identify differences driven by PCP type, duration of relationship with the PCP, awareness of SCDM, and length of IMD/MenB vaccination conversation EO2: To identify factors associated with receipt of the MenB vaccine, proactive health-seeking behaviors, and explicit PCP MenB vaccine recommendation EO3: To evaluate how the COVID-19 pandemic has influenced parents of older adolescents and young adult’s awareness, attitudes, and practices regarding meningococcal disease, MenB vaccination, and barriers to vaccination

^a Given parents’ and patients’ familiarity with the term primary care provider (PCP), this was used in place of healthcare provider throughout the study.

Abbreviations. COVID-19, coronavirus disease 2019; IMD, invasive meningococcal disease; MenB, meningococcal serogroup B; PCP, primary care provider; SCDM, shared clinical decision-making; US, United States.

Awareness of IMD and MenB vaccination

IMD

To address the primary objective of the study, participants’ awareness of MenB disease was evaluated (Table 2; PO1). Compared to non-vaccinated participants, both parents of vaccinated adolescents and vaccinated young adults demonstrated a higher awareness of IMD risks, causes, how to protect against the disease, and symptoms, as well as how the disease is spread, diagnosed, and treated.

Table 2. Parents’ and young adults’ awareness of MenB disease, MenB vaccination, and other vaccinations.

	Parents of Adolescents 16–18-years-old				Young Adults 19–23-years-old
	Vaccinated		Non-Vaccinated		Vaccinated		Non-Vaccinated
	N = 151		N = 154		N = 150		N = 151
Awareness of	n	%	n	%	n	%	n	%
Meningitis B disease before responding to survey (n, %)	N/A	N/A	154	100.0%	N/A	N/A	151	100.0%
Yes	N/A	N/A	104	67.5%	N/A	N/A	88	58.3%
No	N/A	N/A	50	32.5%	N/A	N/A	63	41.7%
Meningitis^a characteristics
Cause of meningitis (n, %)	151	100.0%	154	100.0%	150	100.0%	151	100.0%
Yes	106	70.2%	81	52.6%	92	61.3%	47	31.1%
No	35	23.2%	54	35.1%	48	32.0%	82	54.3%
Unsure/Don’t Know	10	6.6%	19	12.3%	10	6.7%	22	14.6%
Symptoms of meningitis (n, %)	151	100.0%	154	100.0%	150	100.0%	151	100.0%
Yes	118	78.1%	83	53.9%	92	61.3%	47	31.1%
No	26	17.2%	50	32.5%	45	30.0%	80	53.0%
Unsure/Don’t Know	7	4.6%	21	13.6%	13	8.7%	24	15.9%
Risks of meningitis (n, %)	151	100.0%	154	100.0%	150	100.0%	151	100.0%
Yes	122	80.8%	89	57.8%	104	69.3%	68	45.0%
No	24	15.9%	46	29.9%	36	24.0%	66	43.7%
Unsure/Don’t Know	5	3.3%	19	12.3%	10	6.7%	17	11.3%
How meningitis spreads (n, %)	151	100.0%	154	100.0%	150	100.0%	151	100.0%
Yes	110	72.8%	78	50.6%	85	56.7%	50	33.1%
No	30	19.9%	53	34.4%	52	34.7%	77	51.0%
Unsure/Don’t Know	11	7.3%	23	14.9%	13	8.7%	24	15.9%
How meningitis is diagnosed (n, %)	151	100.0%	154	100.0%	150	100.0%	151	100.0%
Yes	100	66.2%	66	42.9%	75	50.0%	39	25.8%
No	38	25.2%	65	42.2%	65	43.3%	91	60.3%
Unsure/Don’t Know	13	8.6%	23	14.9%	10	6.7%	21	13.9%
How meningitis is treated (n, %)	151	100.0%	154	100.0%	150	100.0%	151	100.0%
Yes	96	63.6%	73	47.4%	80	53.3%	36	23.8%
No	41	27.2%	59	38.3%	57	38.0%	89	58.9%
Unsure/Don’t Know	14	9.3%	22	14.3%	13	8.7%	26	17.2%
How to protect from meningitis (n, %)	151	100.0%	154	100.0%	150	100.0%	151	100.0%
Yes	124	82.1%	89	57.8%	104	69.3%	55	36.4%
No	18	11.9%	45	29.2%	37	24.7%	74	49.0%
Unsure/Don’t Know	9	6.0%	20	13.0%	9	6.0%	22	14.6%
Meningitis symptoms (n, %)
Fever	120	79.5%	99	64.3%	96	64.0%	60	39.7%
Headache	111	73.5%	96	62.3%	84	56.0%	64	42.4%
Stiff neck	111	73.5%	83	53.9%	69	46.0%	39	25.8%
Nausea	81	53.6%	63	40.9%	80	53.3%	59	39.1%
Vomiting	74	49.0%	71	46.1%	67	44.7%	51	33.8%
Photophobia (eyes being more sensitive to light)	53	35.1%	47	30.5%	43	28.7%	25	16.6%
Altered mental status (confusion)	76	50.3%	67	43.5%	55	36.7%	28	18.5%
Other	6	4.0%	1	0.6%	3	2.0%	1	0.7%
Don’t know any of these to be symptoms of meningitis	9	6.0%	25	16.2%	23	15.3%	60	39.7%
Meningitis B vaccine before responding to survey (n, %)	N/A	N/A	154	100.0%	N/A	N/A	151	100.0%
Yes	N/A	N/A	94	61.0%	N/A	N/A	75	49.7%
No	N/A	N/A	60	39.0%	N/A	N/A	76	50.3%
Vaccines previously heard of (n, %)
Influenza/Flu shot	140	92.7%	126	81.8%	131	87.3%	119	78.8%
COVID-19	132	87.4%	133	86.4%	134	89.3%	132	87.4%
Meningitis B (also known as Bexsero or Trumenba)	136	90.1%	90	58.4%	124	82.7%	65	43.0%
Meningitis ACWY (also known as Menactra, Menveo, or MenQuadfi)	104	68.9%	69	44.8%	93	62.0%	47	31.1%
Tetanus, Diphtheria, and Pertussis – Tdap (also known as Boostrix or Adacel)	131	86.8%	118	76.6%	117	78.0%	90	59.6%
Human Papillomavirus (HPV) (also known as Gardasil 9)	128	84.8%	108	70.1%	112	74.7%	75	49.7%
None of the above	2	1.3%	7	4.5%	2	1.3%	12	7.9%

^a “Meningitis” was used to refer to IMD for the purposes of the questionnaire to accommodate parents’ and patients’ familiarity with the term. “Meningitis B disease” was used to refer specifically to MenB disease.

Abbreviations. COVID-19, coronavirus disease 2019; HPV, human papilomavirus; MenACWY, meningococcal serogroups A, C, W, and Y; MenB, meningococcal serogroup B; N/A, not applicable; Tdap, tetanus, diptheria, and pertussis.

Awareness was lower among non-vaccinated than among vaccinated participants, though within non-vaccinated cohorts, parents reported higher awareness of MenB disease and IMD’s characteristics than young adults. Before responding to the survey, 104 (67.5%) parents of non-vaccinated adolescents had heard of MenB disease. The majority of parents in this cohort were aware of IMD cause (n = 81; 52.6%), symptoms (n = 83; 53.9%), risks (n = 89; 57.8%), spread (n = 78; 50.6%), and protection (n = 89; 57.8%), though less than half were aware of how IMD is diagnosed (n = 66; 42.9%) and treated (n = 73; 47.4%). In contrast, awareness of IMD characteristics was low overall for non-vaccinated young adults: only 88 (58.3%) had heard of MenB disease, and less than half were aware of IMD cause (n = 47; 31.1%), symptoms (n = 47; 31.1%), risks (n = 68; 45.0%), spread (n = 50; 33.1%), diagnosis (n = 39; 25.8%), treatment (n = 36; 23.8%), and protection (n = 55; 36.4%).

MenB vaccination

Participants’ awareness of MenB vaccination was also evaluated (Table 2; PO1). The majority of parents of non-vaccinated adolescents were aware of the MenB vaccine prior to the survey (n = 94; 61.0%), compared with around half of non-vaccinated young adults (n = 75; 49.7%). Meanwhile, among vaccinated cohorts, most parents (n = 81; 53.6%) were aware that MenB vaccination was a series of doses, compared with less than half of young adults (n = 68; 45.3%).

To better situate these results, participants’ awareness of other common vaccinations was also evaluated (Table 2). When asked in a multiple-choice format which vaccinations they had previously heard of, for non-MenB-vaccinated adolescents, the majority of the parents had previously heard of the following vaccinations: COVID-19 (n = 133; 86.4%), influenza (n = 126; 81.8%), Tdap (n = 118; 76.6%), HPV (n = 108; 70.1%), and MenB (n = 90; 58.4%). Meanwhile, among non-MenB-vaccinated young adults, while the majority had previously heard of COVID-19 (n = 132; 87.4%), influenza (n = 119; 78.8%) and Tdap (n = 90; 59.6%) vaccinations, less than half had heard about HPV (n = 75; 49.7%), MenB (n = 65; 43.0%), and MenACWY (n = 47; 31.1%) vaccinations.

Attitudes related to IMD and MenB vaccination

Participants reported their perceived risk of contracting IMD and potential impact of IMD, as well as their interest in learning about IMD (Table 3; SO1).

Table 3. Attitudes towards meningitis vaccination among parents and young adults.

	Parents of Adolescents 16–18-years-old				Young Adults 19–23-years-old
	Vaccinated		Non-Vaccinated		Vaccinated		Non-Vaccinated
	N = 151		N = 154		N = 150		N = 151
Attitudes towards	n	%	n	%	n	%	n	%
Perceived risk of contracting meningitis (n, %)*
In the next year (n, %)	151	100.0%	154	100.0%	150	100.0%	151	100.0%
Likely (Likert scale 6–7)	21	13.9%	25	16.2%	12	8.0%	10	6.6%
Neutral (Likert scale 3–5)	40	26.5%	41	26.6%	34	22.7%	29	19.2%
Not likely (Likert scale 1–2)	90	59.6%	88	57.1%	104	69.3%	112	74.2%
In the next 5 years (n, %)	151	100.0%	154	100.0%	150	100.0%	151	100.0%
Likely (Likert scale 6–7)	24	15.9%	24	15.6%	18	12.0%	11	7.3%
Neutral (Likert scale 3–5)	44	29.1%	52	33.8%	37	24.7%	45	29.8%
Not likely (Likert scale 1–2)	83	55.0%	78	50.6%	95	63.3%	95	62.9%
Over lifetime (n, %)	151	100.0%	154	100.0%	150	100.0%	151	100.0%
Likely (Likert scale 6–7)	27	17.9%	30	19.5%	22	14.7%	20	13.2%
Neutral (Likert scale 3–5)	51	33.8%	57	37.0%	53	35.3%	55	36.4%
Not likely (Likert scale 1–2)	73	48.3%	67	43.5%	75	50.0%	76	50.3%
Potential impact of meningitis on life (n, %)**	151	100.0%	154	100.0%	150	100.0%	151	100.0%
Severe (Likert scale 6–7)	81	53.6%	86	55.8%	57	38.0%	54	35.8%
Moderate (Likert scale 3–5)	65	43.0%	60	39.0%	80	53.3%	81	53.6%
No/low impact (Likert scale 1–2)	5	3.3%	8	5.2%	13	8.7%	16	10.6%
Learning about meningitis (n, %)***	151	100.0%	154	100.0%	150	100.0%	151	100.0%
Very interested (Likert scale 6–7)	84	55.6%	83	53.9%	54	36.0%	31	20.5%
Somewhat interested (Likert scale 3–5)	56	37.1%	51	33.1%	70	46.7%	82	54.3%
No/low interest (Likert scale 1–2)	11	7.3%	20	13.0%	26	17.3%	38	25.2%
MenB vaccination (n, %)^
Vaccination is the best way to protect from meningitis (n, %)	151	100.0%	154	100.0%	150	100.0%	151	100.0%
Agree (Likert scale 6–7)	128	84.8%	95	61.7%	94	62.7%	81	53.6%
Neutral (Likert scale 3–5)	19	12.6%	49	31.8%	45	30.0%	51	33.8%
Disagree (Likert scale 1–2)	4	2.6%	10	6.5%	11	7.3%	19	12.6%

* 1–7 Likert scale, where 1 = Not at all likely and 7 = Extremely likely.

** 1–7 Likert scale, where 1 = No impact and 7 = Severe impact.

*** 1–7 Likert scale, where 1 = Not at all interested and 7 = Extremely interested.

^ 1–7 Likert scale, where 1 = Completely disagree and 7 = Completely agree.

Abbreviations. MenB, meningococcal serogroup B.

Risk of contracting MenB disease

Overall, parents reported higher levels of concern about the possibility of (their child) contracting IMD than young adults. About half of parents of vaccinated adolescents (n = 76; 50.3%) were very concerned about the possibility of contracting IMD, and 67 (44.4%) were not concerned due to their child having been vaccinated. Meanwhile, among vaccinated young adults, only 31 (20.7%) were concerned about contracting IMD and 69 (46.0%) were not concerned due to having been vaccinated. Among non-vaccinated cohorts, 76 (49.4%) parents and 31 (20.5%) young adults were concerned about possibly contracting IMD.

In the vaccinated cohorts, parents’ perceived risk of their child contracting IMD was low, with only 21 (13.9%), 24 (15.9%), and 27 (17.9%) parents perceiving their child to be at risk for contracting IMD in the next year, next five years, and over their lifetimes, respectively. Even fewer young adults perceived themselves to be at risk of contracting IMD in the next year (n = 12; 8.0%), next five years (n = 18; 12.0%), or over their lifetimes (n = 22; 14.7%). Among non-vaccinated cohorts, parents’ perceived risk of contracting IMD was slightly higher (n = 25 [16.2%], n = 24 [15.6%], and n = 30 [19.5%], over the next year, next five years, and lifetime, respectively) than among young adults (n = 10 [6.6%], n = 11 [7.3%], and n = 20 [13.2%] over the next year, next five years, and lifetime, respectively).

Impact of IMD

Over half of parents (81 [53.6%] and 86 [55.8%] in the vaccinated and non-vaccinated cohorts, respectively) believed that the potential impact of IMD on their adolescent’s life would be severe, compared with over half of vaccinated and non-vaccinated young adults (80 [53.3%] and 81 [53.6%], respectively) who believed that the impact would be moderate.

Learning about IMD

Vaccinated cohorts also expressed a higher interest in learning about IMD than non-vaccinated cohorts, and among the latter, more parents of non-vaccinated adolescents were very interested in learning about meningitis (n = 83; 53.9%) than non-vaccinated young adults (n = 31; 20.5%).

MenB vaccination as a preventative measure

Participants also reported their attitudes towards MenB vaccination as a preventative measure for IMD (Table 3; SO1). Across all respondents, vaccination was considered the best protective measure against IMD, though agreement was higher among vaccinated than non-vaccinated cohorts, with parents of vaccinated adolescents reporting the highest agreement (128 [84.8%] versus [vs.] 95 [61.7%] among parents of non-vaccinated adolescents) compared to young adults (94 [62.7%] vs. 81 [53.6%] among non-vaccinated young adults).

Practices related to meningococcal disease and vaccination

MenB disease-related health-seeking behaviors (i.e. proactive efforts to learn more about MenB disease and prevention from PCPs), use of approaches or resources to inform MenB vaccination decision-making, and self-reported MenB vaccination series initiation and completion were evaluated for vaccinated cohorts (SO2).

IMD-related health-seeking behaviors and vaccination discussion under SCDM

Of parents of vaccinated adolescents (n = 151), the majority were not aware of SCDM recommendations for care and vaccination decisions (n = 98; 64.9%). However, 118 (78.1%) reported having shared in decision-making before receiving the MenB vaccine when provided the definition of SCDM. Similarly, the majority of vaccinated young adults (n = 150) were unaware of SCDM recommendations (n = 82; 54.7%), though 94 (62.7%) shared in decision-making before getting vaccinated.

Among vaccinated cohorts, both parents and young adults relied on PCPs to initiate the MenB vaccination conversation. Among parents of vaccinated adolescents who had discussed MenB vaccination with their PCP (n = 128), 95 (74.2%) reported that the PCP was the one who initiated the conversation, as did 69/112 (61.6%) vaccinated young adults who had discussed MenB vaccination with their PCP (Figure 1). Of those who did initiate the conversation themselves (28 parents and 17 young adults), most did so due to college/school requirements (16 [57.1%] parents and 9 [52.9%] young adults) or because they/their child had discussed MenB disease or vaccination with family or friends (12 [42.9%] parents and 9 [52.9%] young adults; Figure 2).

Figure 1. Who initiated MenB vaccination conversation among parents (of vaccinated adolescents) and among vaccinated young adults.

Abbreviations. NP, nurse practitioner; MenB, meningococcal serogroup B; PA, physician assistant.

Figure 2. Reason for initiating MenB vaccination conversation among parents (of vaccinated adolescents) and among vaccinated young adults.

*E.g. pamphlets, posters, etc.

Abbreviations. IMD, invasive meningococcal disease; MenB, meningococcal serogroup B.

Among those who had discussed MenB vaccination with their PCP (128 parents and 112 young adults), the largest proportion of parents (n = 49; 38.3%) and young adults (n = 40; 35.7%) reported having spent 5–10 minutes discussing MenB vaccination with the PCP, followed by <5 minutes (n = 32; 25.0% and n = 26; 23.2%), 11–20 minutes (n = 25; 19.5% and n = 21; 18.8%), or >20 minutes (n = 16; 12.5% and n = 11; 9.8%), respectively.

The most-discussed topics with PCPs among parents (n = 128) were MenB vaccine importance (n = 86; 67.2%), when their child should receive the first vaccine dose (n = 74; 57.8%), and vaccine effectiveness (n = 68; 53.1%). Among young adults (n = 112), MenB vaccine importance (n = 58; 51.8%), vaccine effectiveness (n = 50; 44.6%), and risks associated with not receiving the vaccine (n = 49; 43.8%) were the most-discussed topics.

Use of resources to inform MenB vaccination decision-making

Among parents of vaccinated adolescents (n = 151), the largest proportion received MenB vaccination information from providers (n = 67; 44.4%), friends/family (n = 29; 19.2%), and/or educational pamphlets provided by the PCP office/clinic (n = 24; 15.9%). Meanwhile, among vaccinated young adults (n = 150), the majority received information from hospital, provider, institution, and/or healthcare websites (n = 38; 25.3%); providers (n = 33; 22.0%); someone who had received the MenB vaccine (n = 33; 22.0%); and/or none of these sources and followed the PCP recommendation (n = 32; 21.3%).

Reported MenB vaccination receipt

Among parents of vaccinated adolescents who had discussed MenB vaccination with their PCP (n = 128), the majority (n = 88; 68.8%) of adolescents received the vaccination right after the conversation at the office/clinic, followed by 18 (14.1%) who were directed to a pharmacy after the conversation. The majority of young adults who had discussed MenB vaccination with their PCP (n = 112) received the vaccination immediately following the conversation at the office/clinic (n = 58; 51.8%), followed by 24 (21.4%) who waited until the next visit. Among vaccinated adolescents (n = 151), only 66 (43.7%) had received ≥1 dose. Similarly, among vaccinated young adults (n = 150), only 58 (38.7%) had received ≥1 dose.

Expectations, preferences, and perceptions regarding MenB vaccination

Expectations of PCPs’ role in MenB vaccination

Participants in the vaccinated cohorts (n = 151 parents; n = 150 young adults) were also asked about their expectations of PCPs regarding MenB vaccination (Table 4; SO3). Over half of parents (n = 114; 75.5%) and young adults (n = 91; 60.7%) considered their PCP to be most responsible for MenB vaccination initiation; only 19 (12.7%) young adults held their parents responsible. Among parents of vaccinated adolescents who had discussed MenB with their adolescent’s PCP (n = 128), 79 (61.7%) felt that the PCP had a significant overall influence on the MenB vaccination decision, compared with only 49/112 (43.8%) young adults who had discussed MenB with their PCP.

Table 4. Expectations, preferences, and perceptions regarding MenB vaccination among vaccinated cohorts.

	Parents of Vaccinated Adolescents 16–18-years-old		Vaccinated Young Adults 19–23-years-old
	N = 151		N = 150
Expectations, Preferences, and Perceptions Regarding MenB Vaccination	n	%	n	%
Responsible for MenB vaccination initiation (n, %)	151	100.0%	150	100.0%
PCP	114	75.5%	91	60.7%
My parent	N/A	0.0%	19	12.7%
Myself	35	23.2%	34	22.7%
Pharmacist	0	0.0%	5	3.3%
Other medical staff	0	0.0%	0	0.0%
Other	2	1.3%	1	0.7%
Meningitis vaccination decision making preferences (n, %)	151	100.0%	150	100.0%
Clear vaccination schedule	47	31.1%	47	31.3%
Discussion with the doctor	40	26.5%	53	35.3%
Both	64	42.4%	50	33.3%
Level of effort from PCP to provide information on MenB vaccine (n, %)*	151	100.0%	150	100.0%
Significant (Likert scale 6–7)	84	55.6%	59	39.3%
Moderate (Likert scale 3–5)	58	38.4%	78	52.0%
None/low (Likert scale 1–2)	9	6.0%	13	8.7%
Perception of vaccine recommendation (n, %)**
PCP made a clear recommendation	151	100.0%	150	100.0%
Agree (Likert scale 6–7)	102	67.5%	76	50.7%
Neutral (Likert scale 3–5)	45	29.8%	60	40.0%
Disagree (Likert scale 1–2)	4	2.6%	14	9.3%
Made decision together with PCP	151	100.0%	150	100.0%
Agree (Likert scale 6–7)	88	58.3%	71	47.3%
Neutral (Likert scale 3–5)	57	37.7%	65	43.3%
Disagree (Likert scale 1–2)	6	4.0%	14	9.3%

* 1–7 Likert scale, where 1 = no effort at all and 7 = a great deal of effort.

** 1–7 Likert scale, where 1 = completely disagree and 7 = completely agree.

Abbreviations. MenB, meningococcal serogroup B; PCP, primary care provider.

Preferences regarding SCDM implementation

Among vaccinated cohorts (n = 151 parents, n = 150 young adults), participants were asked to describe their vaccination decision-making preferences (Table 4; SO4). When asked which option best fit vaccinated respondents’ preferences regarding vaccination decision-making, approximately one-third of parents and young adults (47 [31.1%] and 47 [31.3%], respectively) preferred the option of having a clear vaccination schedule, while 40 (26.5%) and 53 (35.3%), respectively, preferred the option of having a discussion with the PCP and 64 (42.4%) and 50 (33.3%), respectively, preferred to have both options.

Among non-vaccinated cohorts (n = 154 parents, n = 151 young adults), when asked which option best fit preferences regarding vaccination decision-making, 49 (31.8%) parents and 34 (22.5%) young adults preferred a clear vaccination schedule and 41 (26.6%) and 57 (37.7%), respectively, preferred the option of having a discussion with the PCP. The highest proportions of both parents of non-vaccinated adolescents (n = 64; 41.6%) and non-vaccinated young adults (n = 60; 39.7%) preferred to have both options.

Perceptions of the level of effort made by PCPs to provide information on MenB vaccination

Vaccinated cohorts (n = 151 parents; n = 150 young adults) were also asked about their perceptions of the level of effort their PCPs made to provide information on and recommend MenB vaccination (Table 4; SO5). Among parents, 84 (55.6%) reported that their adolescent’s PCP made a significant effort to provide information, vs. the moderate-to-low effort reported by 67 (44.4%). In addition, 102 (67.5%) parents felt that their adolescent’s PCP had made a clear recommendation, and 88 (58.3%) felt that they had made a decision together with their adolescent’s PCP.

This gap in the perceived level of PCP effort to provide information was even more pronounced among vaccinated young adults; 59 (39.3%) reported that a significant effort was made, while 91 (60.7%) reported a moderate-to-low effort. In this cohort, 76 (50.7%) felt that their PCP had made a clear recommendation, and less than half (n = 71; 47.3%) felt they had made a decision together with their PCP.

Barriers to and decision drivers of MenB vaccine series initiation

Among non-vaccinated cohorts, perceived barriers to MenB vaccination and drivers of potential MenB vaccination series initiation were assessed (Table 5; SO6). In addition to lack of awareness of MenB disease (32.5% of parents of non-vaccinated adolescents were unaware) presenting the foremost barrier to vaccination initiation, among parents of non-vaccinated adolescents who were aware of MenB disease (n = 104), the top three barriers to MenB vaccination were reported to be: side effects of the MenB vaccine (n = 28; 26.9%), lack of PCP recommendation (n = 27; 26.0%), and uncertainty around whether MenB vaccination was needed (n = 24; 23.1%). Meanwhile, among all parents of non-vaccinated adolescents (n = 154), 79 (51.3%), 72 (46.8%), and 70 (45.5%) identified PCP recommendation, information demonstrating vaccine safety, and school/college requirements as drivers of potentially receiving a MenB vaccination, respectively.

Table 5. Barriers to and drivers of potential MenB vaccination series initiation among non-vaccinated cohorts.

	Parents of Non-Vaccinated Adolescents 16–18-years-old		Non-Vaccinated Young Adults 19–23-years-old
	N = 154		N = 151
Barriers to MenB Vaccination and Drivers of Potential MenB Vaccination	n	%	n	%
Barriers to MenB vaccination, among those aware of MenB disease	104	N/A	88	N/A
PCP recommendation (n, %)	104	100.0%	88	100.0%
Not mentioned by PCP	20	19.2%	29	33.0%
Not recommended by PCP	27	26.0%	16	18.2%
Not enough information from PCP on the vaccine	10	9.6%	18	20.5%
Conflicting information from PCP about getting the vaccine	13	12.5%	13	14.8%
Recommended by PCP but don’t think it’s needed	10	9.6%	10	11.4%
Unaware of the MenB vaccine	11	10.6%	11	12.5%
External factors (n, %)	104	100.0%	88	100.0%
Difficulty traveling/no time to get vaccination	9	8.7%	12	13.6%
Concerns about cost/insurance coverage	6	5.8%	17	19.3%
Not required by school/college	15	14.4%	16	18.2%
COVID-19 pandemic has prevented me taking the vaccination	17	16.3%	17	19.3%
Personal views (n, %)	104	100.0%	88	100.0%
Allergy/other health condition	9	8.7%	6	6.8%
Afraid of needles/shot	8	7.7%	15	17.0%
I don’t trust vaccines/the CDC/vaccine manufacturers	8	7.7%	8	9.1%
Not sure if needed	24	23.1%	26	29.5%
Not at risk of getting MenB	14	13.5%	19	21.6%
Not worried about contracting MenB	10	9.6%	20	22.7%
Side effects of the vaccine	28	26.9%	20	22.7%
Don’t think the vaccine will work	12	11.5%	5	5.7%
Religious beliefs	4	3.8%	10	11.4%
Influence by family/friends led me to decide not getting the vaccine	7	6.7%	9	10.2%
Influence by healthcare provider led me to decide not getting the vaccine	6	5.8%	6	6.8%
Confusion about two different meningococcal vaccines for the same disease	9	8.7%	11	12.5%
Drivers of potential MenB vaccination (n, %)	154	100.0%	151	100.0%
PCP recommendation	79	51.3%	73	48.3%
Required by school/college	70	45.5%	60	39.7%
Insurance coverage for the vaccine	46	29.9%	63	41.7%
Hearing positive experiences about getting the vaccine from friends or family	49	31.8%	60	39.7%
CDC recommendation to get the vaccine	52	33.8%	50	33.1%
Information that shows the vaccine is safe	72	46.8%	73	48.3%
Information that shows the vaccine works	60	39.0%	67	44.4%
Meningitis outbreak near me	65	42.2%	87	57.6%
Among those previously aware of MenB	50	100.0%	63	100.0%
More information about MenB (n, %)	25	50.0%	25	39.7%
Other	9	5.8%	7	4.6%

Abbreviations. CDC, Centers for Disease Control and Prevention; COVID-19, coronavirus disease 2019; MenB, meningococcal serogroup B; N/A, not applicable; PCP, primary care provider.

Similarly, in addition to the barrier presented by low MenB disease awareness (41.7% of non-vaccinated young adults were unaware), among the 88 (58.3%) non-vaccinated young adults who were aware of MenB disease, PCPs not mentioning the vaccine (n = 29; 33.0%), uncertainty around whether MenB vaccination was needed (n = 26; 29.5%), side effects of the MenB vaccine (n = 20; 22.7%), and/or not being worried about contracting MenB disease (n = 20; 22.7%) were the top barriers. Meanwhile, drivers of potentially receiving a MenB vaccination (perceived by all non-vaccinated young adults [n = 151]) included presence of a nearby meningitis outbreak (n = 87; 57.6%), information demonstrating vaccine safety (n = 73; 48.3%), and PCP recommendation (n = 73; 48.3%).

Barriers to and decision drivers of MenB vaccine series completion

Perceived barriers to and decision drivers of MenB series completion (i.e. receiving ≥2 doses) were also evaluated among vaccinated cohorts who had received only one dose of the MenB vaccine series (Table 6; SO6). Of vaccinated adolescents (n = 151), 69 (45.7%) had received only one dose of the MenB vaccine series at the time of the study. Among parents of these adolescents (n = 69), waiting for enough time to pass to receive the second dose (n = 36; 52.2%), followed by the second dose not being recommended by PCPs (n = 17; 24.6%) and uncertainty about whether the second dose was needed (n = 14; 20.3%) were perceived as the main barriers to series completion. Meanwhile, the same parents reported the top three drivers of series completion to be (1) PCPs recommending the vaccine (n = 35; 50.7%), (2) reminders from PCPs (n = 27; 39.1%), and (3) school/college requirements (n = 26; 37.7%).

Table 6. Barriers to and drivers of potential MenB vaccination series completion among vaccinated cohorts.

	Parents of Vaccinated Adolescents 16–18-years-old		Vaccinated Young Adults 19–23-years-old
	N = 151		N = 150
Barriers to MenB Vaccination Series Completion and Drivers of Potential MenB Vaccination Series Completion	n	%	n	%
PCP recommendation (n, %)	69	100.0%	62	100.0%
Not recommended by PCP	17	24.6%	14	22.6%
Not enough information from PCP on the 2nd dose	7	10.1%	14	22.6%
Conflicting information from PCP about getting the 2nd dose	5	7.2%	12	19.4%
Recommended by PCP but don’t think it’s needed	11	15.9%	17	27.4%
External factors (n, %)
Difficulty traveling/no time to get vaccination	7	10.1%	14	22.6%
Concerns about cost/insurance coverage	6	8.7%	14	22.6%
Waiting for more time to pass to get the 2nd dose	36	52.2%	14	22.6%
Not required by school/college	9	13.0%	21	33.9%
COVID-19 pandemic has prevented me taking the vaccination	6	8.7%	14	22.6%
Personal views (n, %)
Not sure if needed	14	20.3%	20	32.3%
Not at risk of getting MenB	8	11.6%	16	25.8%
Not worried about contracting MenB	5	7.2%	18	29.0%
Side effects of the vaccine	9	13.0%	15	24.2%
Don’t think the vaccine will work	4	5.8%	12	19.4%
Religious beliefs	3	4.3%	5	8.1%
Influence by family/friends led me to decide not getting the vaccine	7	10.1%	10	16.1%
Influence by healthcare provider led me to decide not getting the vaccine	10	14.5%	7	11.3%
Drivers of potential MenB vaccination series completion among those who had received the 1st dose (n, %)
PCP recommendation	35	50.7%	25	40.3%
Required by school/college	26	37.7%	26	41.9%
Insurance coverage for the vaccine	15	21.7%	19	30.6%
Hearing positive experiences about getting the vaccine from friends or family	13	18.8%	15	24.2%
CDC recommendation to get the vaccine	13	18.8%	17	27.4%
Information that shows the vaccine is safe	15	21.7%	14	22.6%
Information that shows the vaccine works	18	26.1%	24	38.7%
Reminder from PCP about when the 2nd dose is due	27	39.1%	15	24.2%
Meningitis outbreak near me	19	27.5%	26	41.9%
Other	1	1.4%	0	0.0%

Abbreviations. CDC, Centers for Disease Control and Prevention; COVID-19, coronavirus disease 2019; MenB, meningococcal serogroup B; PCP, primary care provider.

Among vaccinated young adults who had received only one dose of the MenB vaccine (n = 62; 41.3% of all vaccinated young adults), lack of school/college requirements (n = 21; 33.9%), uncertainty about whether the second dose was needed (n = 20; 32.3%), and not being worried about contracting MenB (n = 18; 29.0%) were the main barriers to series completion. In contrast, the top three drivers of series completion reported by vaccinated young adults who had received only one dose were (1) a nearby meningitis outbreak (n = 26; 41.9%), (2) school/college requirements (n = 26; 41.9%), and (3) PCPs recommending the vaccine (n = 25; 40.3%).

MenB vaccination trends

To better understand trends on key variables surrounding MenB vaccination (EO1), post-hoc cross tables were generated to assess differences driven by (1) PCP type, (2) duration of relationship with PCP, (3) SCDM awareness, and (4) duration of MenB disease/vaccination conversation.

Cross-tables generated to assess differences driven by PCP type found that a higher proportion of pediatricians initiated the MenB conversation among parents of vaccinated adolescents and among vaccinated young adults (83.7% and 64.7%, respectively) compared to other PCP types (Table S5, supplementary material). More parents of vaccinated older adolescents initiated the MenB conversation themselves (12.2–25.9%) compared to vaccinated young adults (5.9–19.6%) across PCP specialties.

Further, across both vaccinated and non-vaccinated cohorts, the longer the duration of relationship between both older adolescents and PCPs or young adults and PCPs, the lower proportion of PCPs who explicitly recommended MenB vaccination (Table S6, supplementary material).

Among vaccinated cohorts, a higher proportion of those who were aware of SCDM took part in SCDM before receiving the MenB vaccine, compared with respondents who were not aware (Table S7, supplementary material). Shorter conversation time was also found to be correlated with a higher likelihood of vaccine administration immediately following the conversation among participants (Table S8, supplementary material).

Factors associated with MenB vaccination

Multivariate regression models were run to evaluate the factors associated with (1) reported MenB vaccination initiation among adolescents (parent-reported) and young adults (self-reported), (2) proactive health-seeking behaviors (i.e. initiating the MenB vaccination conversation), and (3) explicit PCP MenB vaccination recommendation (EO2).

Several modifications were made to the regression models due to sample size and multicollinearity issues. Deviations from definitions used in the survey are detailed in the footnotes for each model’s results.

Receipt of the MenB vaccine

Parents of adolescents who were vaccinated for MenACWY (odds ratio [OR] = 26.25, p < 0.0001) and Tdap (OR = 5.85, p < 0.0001) were significantly more likely to report MenB vaccination initiation than parents of adolescents not vaccinated for MenACWY and Tdap (Figure 3).

Figure 3. Factors significantly associated with self-reported MenB vaccination initiation among parents of adolescents.

Note: Full multivariate regression results are listed in Supplementary Table 9.

Abbreviations. MenACWY, meningococcal serogroups A, C, W, and Y; MenB, meningococcal serogroup B; OR, odds ratio; Tdap, tetanus, diphtheria, and pertussis.

Among young adults, MenB vaccination initiation was significantly more likely among those who were vaccinated for MenACWY (OR = 14.44, p < 0.0001), Tdap (OR = 7.36, p < 0.0001), or HPV (OR = 12.48, p < 0.0001), as well as among those who were female (OR = 3.05, p = 0.030). Insurance status was also found to be a significant predictor of MenB vaccination initiation among young adults, where those who reported having “other” (OR = 0.17, p = 0.007) or multiple (OR = 0.15, p = 0.020) insurance types had lower odds of reporting MenB vaccination initiation compared to those who had commercial insurance (Figure 4).

Figure 4. Factors significantly associated with self-reported MenB vaccination initiation among young adults.

Note. Full multivariate regression results are listed in Supplementary Table 10.

*E.g. having an insurance type other than commercial, Medicare, or Medicaid insurance types or responded “prefer not to answer”.

Abbreviations: HPV, human papillomavirus; MenACWY, meningococcal serogroups A, C, W, and Y; MenB, meningococcal serogroup B; OR, odds ratio; Tdap, tetanus, diphtheria, and pertussis.

Proactive health-seeking behaviors

Among vaccinated cohorts, significantly higher odds of parents or young adults initiating a discussion on MenB vaccination were associated with having visited a PCP 2–5 (OR = 5.21, p < 0.001) or >5 times (OR = 5.24, p = 0.022) per year, as well as the participant thinking of themselves as responsible for initiating MenB vaccine conversation (OR = 3.66, p = 0.003). Participants living in a suburban vs. an urban area were less likely to initiate the discussion on MenB vaccination (OR = 0.34, p = 0.036) (Figure 5).

Figure 5. Factors significantly associated with proactive health-seeking behaviors (i.e. initiating the MenB vaccine discussion) among vaccinated cohorts.

Note: Full multivariate regression results are listed in Supplementary Table 11.

Abbreviations: MenB, meningococcal serogroups B; OR, odds ratio; PCP, primary care provider.

Explicit PCP MenB vaccination recommendation

Among vaccinated cohorts, having received the MenACWY vaccine was significantly associated with higher odds of a PCP explicitly recommending the MenB vaccine (OR = 3.93, p = 0.0003). Meanwhile, higher adolescent and young adult age (OR = 0.70, p = 0.0007), living in a rural area (OR = 0.34, p = 0.040), and having had a MenB conversation duration of >20 minutes (OR = 0.33, p = 0.045) all significantly lowered the likelihood of explicit PCP recommendation (Figure 6).

Figure 6. Factors significantly associated with PCP explicit MenB recommendation among vaccinated cohorts.

Note: Full multivariate regression results are listed in Supplementary Table 12.

*Time spent discussing IMD/MenB vaccination with PCP.

Abbreviations: MenACWY, meningococcal serogroups A, C, W, and Y; MenB, meningococcal serogroup B; OR, odds ratio; PCP, primary care provider.

Influence of COVID-19 on decision to receive MenB vaccination

The influence of COVID-19 on deciding to receive the MenB vaccine was also assessed, and a low correlation overall was found between COVID-19 and intention to vaccinate against other diseases (e.g. MenB; EO3). Among vaccinated cohorts, 55 (36.4%) parents and 45 (30.0%) young adults reported that COVID-19 had significant influence on their decision to receive the MenB vaccine. In contrast, in the non-vaccinated cohorts 69 (44.8%) parents and 84 (55.6%) young adults reported that COVID-19 had no/low influence on their decision to not get the MenB vaccine.

Discussion

This study identified awareness, attitudes, and practices surrounding MenB diseases and vaccination, especially following the 2019 ACIP recommendation change to SCDM, among parents of adolescents 16–18-years-old and among young adults 19–23-years-old.

Participant characteristics were largely consistent with other survey studies of adolescents and young adults vaccinated for MenB and IMD caused by other serogroups, including across race/ethnicity and insurance status.^19–21 Compared to the national average reported in a previous study, we found a slightly higher proportion of respondents living in the US South.¹⁹

Awareness, attitudes, and practices regarding MenB disease and vaccination

Findings from this study point to misperceptions about and lack of awareness of MenB vaccines, which may contribute to low MenB vaccination initiation. While almost all parents in this study (94%) had heard of MenB or meningitis, only 40% of parents reported having heard of the MenB vaccine, consistent with previous studies.^17,18,22 The relatively low incidence of IMD in the general US population may contribute to low awareness of MenB disease and vaccination;⁹ however, there is limited research exploring the relationship between IMD incidence and awareness. In this study, young adults selected the presence of a nearby meningitis outbreak as a potential driver of initiating or completing the MenB vaccine series. Further research is needed to explore how the presence of IMD outbreaks influences the success of public awareness and vaccination programs.

Parents and young adults alike relied on providers to initiate a conversation on MenB vaccination (74% and 62%, respectively), indicating that PCP recommendations carry substantial weight in MenB vaccination decisions. Notably, a clear PCP recommendation was among the most common drivers of potential MenB vaccination initiation among non-vaccinated cohorts. However, the experiences of this study’s participants pointed towards a lack of consistent MenB vaccination discussion initiation by PCPs, where 19% of parents and 33% of young adults in non-vaccinated cohorts reported that MenB vaccination was not mentioned by their PCPs, consistent with findings from the Meningitis B Action Project’s national 2020 study reporting that not all providers are routinely discussing MenB vaccination with their 16–23-year-old patients.²³ A recent study found that physicians’ main reasons for not initiating conversations on MenB vaccination included low patient motivation to receive the vaccine, patients not attending college, and/or patients not disclosing risk factors.¹⁵ These findings further highlight how encouraging PCP implementation of SCDM around MenB vaccination could improve vaccination uptake, as involving parents and patients in decision-making could help increase patient awareness of MenB and encourage disclosure of relevant medical history. Vaccinated cohorts also reported uncertainty on whether the second MenB dose is needed, lack of PCP recommendation for the second dose, and wait time to receive the second dose as barriers to series completion. In addition to encouraging PCPs to recommend the second dose, these barriers could be reduced by having series completion recommended or required by schools or colleges.

This study also found that uptake of other vaccines (e.g. COVID-19), was lower among non-vaccinated cohorts. While anti-vaccination attitudes were not assessed in this study, reported reasons for not vaccinating against MenB may partially represent anti-vaccine trends and could serve as departure points for further exploration into drivers of vaccine hesitancy.

Only 35–45% of vaccinated cohorts (both parents and young adults) were aware of SCDM, indicating a lack of consistency in SCDM implementation. Previous studies have highlighted disparities in provider interpretation and implementation of SCDM recommendations; a 2020 study found that only 7% of providers reported prescribing MenB vaccines consistently with ACIP recommendations, while a 2023 study found that 54% of providers did not know that MenB vaccination is recommended under SCDM.^24,25 With this context, our findings suggest that parents and patients may not receive the appropriate resources and support that would allow them to initiate or contribute in SCDM conversations, in turn contributing to gaps in vaccination. In fact, patients and parents who were aware of SCDM were most likely to take part in SCDM, indicating the importance of ensuring parents and patients are well-informed about their role in vaccination decision-making.

Participants reported a high interest in learning about MenB disease and vaccination, suggesting that if parents and patients were to receive more information from PCPs, they would be more willing to be vaccinated for MenB. A 2019 study similarly found that after caregivers became aware of the MenB vaccine, a high proportion indicated a willingness to have their child vaccinated and learn more about the vaccine.¹⁸ Therefore, there is a potential opportunity to close knowledge gaps by providing patient education to those who are interested in learning more about the disease, vaccine, or their role in vaccination decision-making. Efforts to increase public awareness of IMD through information campaigns are already being led by organizations such as the Meningitis B Action Project (a joint initiative of the Kimberly Coffey Foundation and Emily Stillman Foundation).²⁶

Factors associated with MenB vaccination, proactive health-seeking behaviors, and explicit PCP recommendation

Receiving MenACWY and Tdap vaccines were significant predictors of self-reported MenB initiation across cohorts, supporting previous findings that concomitant vaccine administration is likely to improve vaccine uptake in adolescents and young adults and provides further rationale to consider concomitant administration of MenB vaccines with the MenACWY vaccine series.²⁷ Odds of MenB vaccination discussion also rose with higher PCP visit frequency, likely due to increased opportunities for discussion and SCDM. When participants felt they were the ones most responsible for initiating MenB vaccination conversations, the odds of them initiating the conversation rose, further emphasizing the need for education on SCDM for MenB vaccination.

However, respondents who spent more time discussing MenB with PCPs were less likely to receive an explicit recommendation. This could be explained by the fact that parents and patients who are more cautious of vaccine side effects, unsure about IMD risks, and/or doubtful of vaccination benefit or need are likely to spend more time discussing MenB vaccination with PCPs. Future research should investigate the relationship between PCP and patient/parent conversational duration and dynamics to better understand the impact on MenB vaccination initiation. Respondents living in a rural area vs. a suburban area were also less likely to receive an explicit recommendation from PCPs, consistent with previous studies reporting lower rates of provider recommendations for other vaccinations (e.g. HPV) in rural areas.^28,29 As in those studies, it is possible that some providers are more confident in explaining the vaccine than others, indicating a need for efforts to ensure that rural providers are equipped with the necessary resources and training to educate parents and patients.

Limitations

To be eligible, participants had to have ≥1 PCP visit within the past year to reduce recall bias; for this reason, the inclusion criteria may have biased the respondent sample towards a population with more frequent healthcare system utilization compared to the overall US population. Though efforts were made to obtain a geographically representative sample, the cohorts may also not represent all US parents and young adults in the population of interest (e.g. possible under-representation of disadvantaged/minority populations). Participants’ social determinants of health likely informed their awareness, attitudes, and practices regarding MenB disease and vaccination. Due to high collinearity between household income and both (1) parent employment status and (2) adolescent insurance, household income was removed from the regression model.

Limitations inherent to survey-based studies were also present. Awareness of and adherence to vaccination were self-reported and may not reflect actual practice, and possible recall bias could have contributed to over- or underestimation of responses (e.g. frequency of PCP visits). As with any feasible administration mode (i.e. mail, electronic, telephone interview), there is a risk that participants could have looked up answers while completing the web-based survey. Another possible limitation was learning bias, as survey question order was not randomized.³⁰

Regarding the study scope and design, as the views of adolescents 16–18-years-old were primarily captured via parents due to state variability on vaccination consent requirements, adolescents’ direct views on IMD awareness and vaccination were not available. Future research evaluating discrepancies between adolescents’ and their parents’ views regarding MenB vaccination could provide useful context. Furthermore, awareness, attitudes, and practices of young adults and parents were limited to MenB and did not assess those on MenACWY booster vaccination.

Conclusions

This US-based study identified gaps in IMD and MenB vaccination awareness among parents of adolescents and among young adults regardless of MenB vaccination status and illustrates that a considerable proportion of parents and young adults are not aware of SCDM. Targeted disease education for patients on IMD epidemiology and risks, paired with medical education for providers, including on ACIP recommendations, may help close these gaps and facilitate more opportunities to discuss MenB vaccines.

Transparency

Author contributions

Substantial contributions to study conception and design: OHR, ZZ, AK, WJC, EO, JKM, RT, LS, CCC, SP, DEC; substantial contributions to analysis and interpretation of the data: OHR, ZZ, AK, WJC, EO, JKM, RT, LS, CCC, SP, DEC; drafting the article or revising it critically for important intellectual content: OHR, ZZ, AK, WJC, EO, JKM, RT, LS, CCC, SP, DEC; final approval of the version of the article to be published: OHR, ZZ, AK, WJC, EO, JKM, RT, LS, CCC, SP, DEC.

Acknowledgements

The authors acknowledge Audrey Colliou, GSK, Wavre, Belgium, for study delivery and contribution to study design, data interpretation, and study completion; and Seongbin Shin, GSK, Philadelphia, USA, for publication management and support. The authors also thank Costello Medical for editorial assistance and publication coordination, on behalf of GSK, and acknowledge Océane Parker, Costello Medical, USA for medical writing and editorial assistance based on authors’ input and direction.

The data presented in this manuscript were also presented in two posters at the 2023 Pediatric Academic Societies (PAS) Meeting.

Declaration of funding

This study was sponsored by GlaxoSmithKline Biologicals SA (Study identifier HE-218668). Support for third-party writing assistance for this article, provided by Océane Parker, Costello Medical, USA, was funded by GSK in accordance with Good Publication Practice (GPP 2022) guidelines (https://www.ismpp.org/gpp-2022).

Declaration of financial/other relationships

OHR, WJC, EO, SP, and DEC are employees and stockholders of the GSK group of companies. JKM, AK, ZZ, RT, LS, and CCC are employees of IQVIA, which was paid by GSK to conduct this study. ZZ also previously worked as a consultant to GSK.

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Data availability statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.