To characterize provider-parent vaccine communication and determine the influence of specific provider communication practices on parent resistance to vaccine recommendations.
We conducted a cross-sectional observational study in which we videotaped provider-parent vaccine discussions during health supervision visits. Parents of children aged 1 to 19 months old were screened by using the Parent Attitudes about Childhood Vaccines survey. We oversampled vaccine-hesitant parents (VHPs), defined as a score ≥50. We developed a coding scheme of 15 communication practices and applied it to all visits. We used multivariate logistic regression to explore the association between provider communication practices and parent resistance to vaccines, controlling for parental hesitancy status and demographic and visit characteristics.
We analyzed 111 vaccine discussions involving 16 providers from 9 practices; 50% included VHPs. Most providers (74%) initiated vaccine recommendations with presumptive (eg, “Well, we have to do some shots”) rather than participatory (eg, “What do you want to do about shots?”) formats. Among parents who voiced resistance to provider initiation (41%), significantly more were VHPs than non-VHPs. Parents had significantly higher odds of resisting vaccine recommendations if the provider used a participatory rather than a presumptive initiation format (adjusted odds ratio: 17.5; 95% confidence interval: 1.2–253.5). When parents resisted, 50% of providers pursued their original recommendations (eg, “He really needs these shots”), and 47% of initially resistant parents subsequently accepted recommendations when they did.
How providers initiate and pursue vaccine recommendations is associated with parental vaccine acceptance.
Comments
Re:Presumptive initiations in vaccine discussions with parents: acquiescence but at what cost?
We appreciate the comments made by Leask and colleagues(1) in response to our recent study.(2) We believe that discussion and debate regarding how best to communicate with parents, especially those who are hesitant about vaccines, is both valuable and beneficial to broadening our understanding of this issue. We have two comments to make in reply.
First, we agree with Leask and colleagues that the methodological limitations inherent to our study preclude us from making broad and generalizable conclusions regarding what constitutes the most effective provider communication style. As discussed in our paper, we were particularly limited by the use of an intermediary outcome (i.e., parent resistance) rather than an end outcome (i.e., vaccine uptake) and by excluding measurement of other potentially important variables related to parent experience and decision-making. In anticipation of this, we collected additional data during our study - including that on parents' vaccine uptake and end-of-visit satisfaction - that begins to address these limitations, and are currently in the process of preparing these data for publication. We are also beginning a longitudinal study to ascertain the association between specific communication practices and vaccine uptake over time.
Second, motivational interviewing (MI) certainly represents a promising framework for communicating with vaccine-hesitant parents. It has a solid grounding in behavior-change theory and has been shown to have some effectiveness in other clinical settings in which behavior change is desired, such as smoking(3) and substance abuse.(4) That said, there are currently no data on the effectiveness of MI in the context of childhood vaccination. Thus, whether or not a 'guiding' communication style is most effective in changing vaccine-hesitant parents' behavior remains speculative. As such, we too express caution in making firm conclusions in the absence of data.
A central rationale for our study was to begin to move beyond the literature's admittedly rich theoretical and conceptual understanding of processes of communicating with vaccine-hesitant parents to how such processes actually play out in real time and circumstances. We need data on the operation and effects of specific communication practices in the childhood vaccine setting to both enrich current theory and help primary care pediatric providers navigate these practical dilemmas. There is a long way to go in this process, and our study only represents a beginning. We suspect there is much to learn along the way.
Conflict of Interest:
None declared
Presumptive initiations in vaccine discussions with parents: acquiescence but at what cost?
With vaccine hesitancy on the rise, finding ways to address it is increasingly important. Opel and colleagues have made a valuable contribution through developing a measure of parental vaccine hesitancy and describing provider communication styles.(1, 2) In their recent examination of interactions between providers and vaccine hesitant parents, they concluded that a 'presumptive initiation' followed by pursuit of a vaccine recommendation was associated with less resistance to vaccination among parents and, hence, a collaborative communication style may need to be reconsidered.(3)
We believe that much more caution needs to be applied to this study's conclusions. Furthermore, we suggest that the presumptive approach could lead to lower vaccine acceptance and completion in the longer term through a failure to adequately address parental concerns.
A key methodological limitation of the Opel et al study is that the primary outcome measure was verbal resistance to vaccination and it is not possible to generalize about the impact of a presumptive format on vaccine uptake. Indeed, a hesitant parent's acquiescence under a presumptive style may result in feelings of conflict and resentment, loss of trust and avoidance of subsequent vaccination visits. This is supported by a recent systematic review finding lower vaccine uptake is associated with parents feeling the discussion with health professionals about their immunization concerns was inadequate in length and depth, dismissive and difficult.(4) In Opel et al's study, the inclusion of variables such as informed decision-making, satisfaction with decision, decisional conflict, self- efficacy, post-consultation vaccine hesitancy, and vaccine completion would have enabled the study to draw more comprehensive conclusions about the true impact of the interaction styles.
The dichotomization of these interaction styles into either a presumptive or participatory format is the second limitation of Opel et al's study. Statements like "What do you want to do about shots?" does not invite participation as implied here. Rather it places responsibility for decision making on the parent. In the field of shared decision making, this is known as patient abandonment and it is not helpful for reaching shared decisions.
Lessons can be learnt from Motivational Interviewing, which identifies three communication styles: directing (described in Opel et al as 'presumptive'), guiding, and following (described as 'participatory'). A guiding style would enable practitioners to make a recommendation and also provide parents with the opportunity to voice their concerns.(5, 6) Related to this point, the role of ensuring valid consent in the context of a presumptive style is not made clear. Only 38% of providers elicited the parents' questions or concerns about vaccinations and the rationale for, and side effects of, vaccines were only discussed in half of the consultations. This finding underpins the need for up-skilling practitioners so that valid consent and vaccine hesitancy are more completely addressed.
Falling vaccination rates due to parental concerns about vaccine safety and efficacy would prima facie require interventions that effectively address parental concerns. Hence, the question remains as to whether an interaction style that more successfully addresses parental concerns will foster more sustainable trust between parents and providers and improve vaccine completion in the longer term.
References
1. Opel DJ, Taylor JA, Mangione-Smith R, Colomon C, Zhao C, Catz S, et al. Validity and reliability of a survey to identify vaccine-hesitant parents. Vaccine. 2011;29:6598-605.
2. Opel DJ, Robinson JD, Heritage J, Korfiatis C, Taylor JA, Mangione -Smith R. Characterizing providers' immunization communication practices during health supervision visits with vaccine-hesitant parents: A pilot study. Vaccine. 2012;30(7):1269-75.
3. Opel DJ, Heritage J, Taylor JA, Mangione-Smith R, Salas HS, DeVere V, et al. The architecture of provider-parent vaccine discussions at health supervision visits. Pediatrics. 2013.
4. Brown KF, Kroll JS, Hudson MJ, Ramsay M, Green J, Long SJ, et al. Factors underlying parental decisions about combination childhood vaccinations including MMR: a systematic review. Vaccine. 2010;28(26):4235 -48.
5. Rollnick S, Butler CC, Kinnersley P, Gregory J, Mash B. Motivational interviewing. BMJ. 2010;340(apr27_2):c1900.
6. Leask J, Kinnersley P, Jackson C, Cheater F, Bedford HE, Rowles G. Communicating with parents about vaccination: a framework for health professionals. 2012;12(154):1471-2431.
Conflict of Interest:
Douglas Opel's group supported accommodation for Julie Leask and hosted her for meetings and a seminar in Seattle in 2012.