Provider Approach to Parental Resistance to Childhood Vaccination: What Works Best?

Provider Approach to Parental Resistance to Childhood Vaccination: What Works Best? CME

News Author: Troy Brown, RN
CME Author: Charles P. Vega, MD, FAAFP

CME Released: 11/13/2013; Valid for credit through 11/13/2014

Clinical Context

More parents are refusing or delaying childhood vaccines, which constitutes a significant public health problem. A study by Kempe and colleagues, which appeared in the May 2011 issue of the American Journal of Preventive Medicine, evaluated this phenomenon. Only 8% of providers surveyed reported rates of vaccine refusal in their practice of 10% or more, but 1 in 5 providers reported that at least 10% of parents requested to delay scheduled vaccines for children. More than half of providers reported taking at least 10 minutes to counsel families with vaccine concerns, and nearly two thirds of providers acquiesced to requests to delay vaccines. Providers believed that personal stories about what they would do for their own children were most effective in convincing parents to vaccinate their offspring.

Given this background, how do most clinicians approach the subject of vaccinating children, and are certain communication styles more effective in reducing parental resistance toward vaccination? The current study by Opel and colleagues examines this issue.

Study Synopsis and Perspective

The approach a clinician uses to discuss vaccinations plays a significant role in whether or not parents choose to have their child vaccinated at that visit, according to across-sectional observational study in which 111 provider–parent vaccine discussions during health supervision visits were recorded and analyzed.

Douglas J. Opel, MD, MPH, an assistant professor in the Division of Bioethics and the Division of General Pediatrics, Department of Pediatrics, University of Washington School of Medicine, Seattle, and at the Treuman Katz Center for Pediatric Bioethics at Seattle Children's Hospital, Seattle Children's Research Institute, Seattle, Washington, and colleagues report their findings in an article published online November 4 in Pediatrics.

"Although the linguistic format of how a topic is introduced has received attention in other medical settings, it has not yet been explored in the context of vaccine discussions," the authors write.

The study included parents of children aged 1 to 19 months who were screened with the Parent Attitudes about Childhood Vaccines survey. Vaccine-hesitant parents (VHPs) were defined as those having a score of 50 or higher. The researchers developed a coding scheme of 15 communication practices and applied it to all patient encounters.

A provider was using a presumptive format when he or she presumed that the parent would be willing to have the child vaccinated that day (eg, "Well, we have to do some shots"). Providers who used a participatory linguistic format (eg, "What do you want to do about shots?" "Are we going to do shots today?") gave the parent more decision-making latitude.

In multivariate logistic regression analyses, the researchers controlled for parental hesitancy status and demographic and visit characteristics.

A total of 111 vaccine discussions took place among 16 providers from 9 practices, half of which included VHPs. Three fourths (74%) of providers began vaccine recommendations with presumptive vs participatory formats.

Among the parents who were resistant to provider initiation (41%), a significantly higher number were VHPs than non-VHPs. Parents were significantly more likely to resist vaccine recommendations if the provider used a participatory instead of a presumptive initiation format (adjusted odds ratio, 17.5; 95% confidence interval, 1.2 - 253.5).

Half of the providers handled parental resistance by repeating their original recommendations (eg, "He really needs these shots"), and when that happened, almost half (47%) of parents who were initially resistant then accepted those recommendations.

Longitudinal studies will need to be conducted with a more diverse population of parents and healthcare providers, the researchers note.

"How providers initiate their vaccine recommendations at health supervision visits appears to be an important determinant of parent resistance to that recommendation," the authors write. "[I]f providers continue to pursue their original recommendation after encountering parental resistance, many parents eventually agree to it," they conclude.

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online November 4, 2013.

Study Highlights

• Study data were drawn from a practice-based research group in Seattle, Washington. Researchers focused on preventive visits for children between ages 1 and 19 months. All visits occurred in 2011 and 2012.
• Parents were asked to complete the Parent Attitudes about Childhood Vaccine survey, which identifies VHPs.
• The preventive health visits were recorded and were fully transcribed. Experts in conversation analysis assessed provider communication and patterns of parent resistance. Specifically, researchers were interested in whether certain communication styles were associated with higher parental resistance to vaccination.
• 16 pediatric providers participated in the study, and researchers evaluated a total of 111 patient visits. Most participating parents were married, white mothers who were at least 30 years old and had an annual household income in excess of $75,000.
• The researchers purposefully oversampled VHPs, who constituted half of the study sample. 41% of parents voiced resistance to vaccines during the interview, with the majority of these parents explicitly rejecting the provider's recommendations.
• 74% of providers initiated the discussion of vaccines with presumptive statements, essentially telling the parent what was going to be done on this visit.
• However, providers were more likely to use a participatory invitation to consider vaccines when speaking with a VHP.
• 83% of parents resisted vaccine recommendations when providers used a participatory format to discuss vaccines, whereas only 26% of parents resisted a presumptive communication style on the part of the provider. The adjusted odds ratio for parental resistance associated with a participatory vs presumptive style was 17.5 (95% confidence interval, 1.2 - 253.5).
• When faced with parental resistance, half of providers persisted with their recommendations for vaccination, regardless of whether the parent was a VHP.
• 47% of parents who were initially resistant to vaccination accepted the provider's recommendation after persistent recommendations to vaccinate.

Clinical Implications

• In a previous study by Kempe and colleagues, providers believed that personal stories about what they would do for their own children were most effective in convincing parents to vaccinate their children.
• In the current study by Opel and colleagues, a presumptive communication style vs a participatory style on the part of the provider appeared to decrease parental resistance to childhood vaccination.

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