Elsevier

Vaccine

Volume 30, Issue 7, 8 February 2012, Pages 1269-1275
Vaccine

Characterizing providers’ immunization communication practices during health supervision visits with vaccine-hesitant parents: A pilot study

https://doi.org/10.1016/j.vaccine.2011.12.129Get rights and content

Abstract

Objective

To determine the feasibility of using direct observation of provider–parent immunization discussions and to characterize provider communication practices with vaccine-hesitant parents.

Methods

Over a 6 month period in 2010, we videotaped immunization discussions between pediatric providers and vaccine-hesitant parents during health supervision visits involving children 2–15 months old (N = 24) in the Seattle area, Washington, USA. Videotapes were analyzed using the qualitative method of conversation analysis.

Results

We approached 96 parents seen by 9 different providers. Of those who were eligible (N = 56), we enrolled 43% (N = 24). Four videotaped visits were excluded from analysis for failure to obtain parental HIPAA authorization. Of the remaining 20 visits, there were ≥2 visits each that involved children aged 2, 4, 6, 9, 12, and 15 months, and all videotaped visits contained at least a brief immunization discussion. We identified 6 communication practices and several behavior types within each practice relevant to immunization: Practice 1, providers’ initiations of the topic of vaccination; Types: participatory or presumptive format; Practice 2, parents’ responses to providers’ topic initiations; Types: strong or weak acceptance or resistance; Practice 3, providers’ follow-ups to parent's responses; Types: no, immediate, or delayed pursuit; Practice 4, parents’ vaccine-related questions or statements; Types: fact- or concern-based; Practice 5, providers’ explicit solicitations of parent's questions/concerns; Types: designed to discourage or encourage discussion; and Practice 6, parents’ responses to providers’ solicitations of questions/concerns; Types: no question or fact- or concern-based inquiry.

Conclusion

Direct observation of immunization discussions in the primary care pediatric setting is feasible and yields insight into several provider–parent immunization communication practices that are worthy of further study to determine which are effective at improving parental acceptance of immunization.

Highlights

► We directly observed outpatient provider–parent immunization discussions. ► Direct observation in this setting is feasible. ► Six provider immunization communication practices are characterized.

Introduction

There is accumulating evidence to suggest that the number of US parents who have delayed or refused some childhood vaccines is increasing [1], [2] and that parents are regularly requesting to use alternative childhood immunization schedules [3], [4], [5]. Waning public trust and confidence in immunizations, however, is not confined to the US [6]. In Australia, for instance, the predominant reason for incomplete childhood immunizations is negative parental attitudes and beliefs towards immunizations [7]. In the United Kingdom, coverage rates for measles-mumps-rubella (MMR) vaccine are only now increasing after years of decline (and increases in the number of cases of measles) following the publication of the now discredited study by Andrew Wakefield and colleagues in 1998 [8], a study which evidence suggests played an important role in decreasing confidence in vaccines and trust in the medical profession [9], [10], [11].

Although there are several factors that influence parents’ decisions to accept or refuse childhood immunization [12], the most important may be their child's health care provider [13], [14], [15], [16]. Parents not only turn to their child's provider for immunization information [17], [18], [19] but also change their minds about delaying or refusing a vaccine after consulting with providers [20]. Despite the importance of the child's provider in parental decision-making about immunization, there is no current standard clinical approach to communicating with vaccine-hesitant parents (VHPs).1 Some believe that “open communication” is essential, others take a “strong stance” towards VHPs, and still others are resigned to not being able to “convince parents about the value of certain vaccines” [21]. This lack of a communication standard has resulted in divergent approaches to the care of VHPs: although the American Academy of Pediatrics’ (AAP) Committee on Bioethics’ recommends against discontinuing care with families who refuse or delay immunization [22], a recent US national survey found that nearly 30% of pediatricians reported that they would do so [23].

A chief reason for the lack of a communication standard with VHPs is that there are minimal data regarding how pediatricians communicate with VHPs about immunization. Consequently, there is little evidence base for problem-assessment and training. The few studies that do exist utilize non-ideal methods for capturing verbal and non-verbal aspects of provider–parent communication, such as self-report [4] and standardized patients [24], [25], or use a more advantageous approach like direct observation [26] but are focused on the nurse–parent interaction and strategies for empowering parents [27]. To our knowledge, there are no studies involving direct observation of pediatricians’ immunization communication practices with parents. The objectives of this study were to determine the feasibility of using direct observation of provider–parent immunization discussions during a sample of pediatric primary care encounters and to begin to characterize provider communication practices with VHPs.

Section snippets

Study participants

Health care providers were recruited from the Puget Sound Pediatric Research Network (PSPRN), a regional practice-based research network based in Seattle, WA. PSPRN includes over 50 pediatricians in primary care practices that are situated in varied areas (urban, suburban, and rural) and encompass different settings (private practices and an inner-city community clinic). Parents of children 2–15 months old being seen for a health supervision visit with a participating provider were approached

Feasibility

We recruited 9 providers (5 men, 4 women) from 6 different pediatric practices to yield a participation rate of 17%. Eight of the participating providers were pediatricians and 1 was a pediatric nurse practitioner. The participating providers’ practices included a university-based clinic, an inner-city community clinic, a private clinic in an urban setting, and 3 private, suburban clinics. In total, these practices serve a racially and economically diverse population.

Over a 5 month enrollment

Discussion

To our knowledge, this is the first study that demonstrates the use of direct observation of actual immunization discussions between VHPs and their child's pediatrician to understand provider–parent communication about immunizations. Given the influential role pediatric providers play in parental immunization decision-making, investigations into how providers communicate with VHPs is an essential first step in eventually determining which communication practices are effective. Knowledge of

Conclusions

Direct observation of immunization discussions during primary care pediatric visits is feasible and yields insight into provider–parent communication practices. We identified 6 communication practices and behavior types within these practices that are worthy of further study in efforts to determine which behaviors are effective at improving parental acceptance of immunization. A larger, more diverse sample of visits is needed to further validate this characterization of provider–parent

References (57)

  • P.J. Smith et al.

    Association between delayed or refused vaccination doses and timely vaccination coverage

  • S.B. Omer et al.

    Nonmedical exemptions to school immunization requirements: secular trends and association of state policies with pertussis incidence

    JAMA

    (2006)
  • A.F. Dempsey et al.

    Alternative vaccination schedule preferences among parents of young children

    Pediatrics

    (2011)
  • A. Wightman et al.

    Washington state pediatricians’ attitudes toward alternative childhood immunization schedules

    Pediatrics

    (2011)
  • G.L. Lawrence et al.

    Reasons for incomplete immunisation among Australian children. A national survey of parents

    Aust Fam Physician

    (2004)
  • M. Evans et al.

    Parents’ perspectives on the MMR immunisation: a focus group study

    Br J Gen Pract

    (2001)
  • L.A. Sturm et al.

    Parental beliefs and decision making about child and adolescent immunization: from polio to sexually transmitted infections

    J Dev Behav Pediatr

    (2005)
  • J.A. Taylor et al.

    The influence of provider behavior, parental characteristics, and a public policy initiative on the immunization status of children followed by private pediatricians: a study from Pediatric Research in Office Settings

    Pediatrics

    (1997)
  • P.J. Smith et al.

    Association between health care providers’ influence on parents who have concerns about vaccine safety and vaccination coverage

    Pediatrics

    (2006)
  • J.A. Taylor et al.

    Parental attitudes toward varicella vaccination. The Puget Sound Pediatric Research Network

    Arch Pediatr Adolesc Med

    (2000)
  • B.G. Gellin et al.

    Do parents understand immunizations? A national telephone survey

    Pediatrics

    (2000)
  • D.A. Gust et al.

    Underimmunization among children: effects of vaccine safety concerns on immunization status

    Pediatrics

    (2004)
  • D. Gust et al.

    Immunization attitudes and beliefs among parents: beyond a dichotomous perspective

    Am J Health Behav

    (2005)
  • D.A. Gust et al.

    Parents with doubts about vaccines: which vaccines and reasons why

    Pediatrics

    (2008)
  • D.S. Diekema

    Responding to parental refusals of immunization of children

    Pediatrics

    (2005)
  • E.A. Flanagan-Klygis et al.

    Dismissing the family who refuses vaccines: a study of pediatrician attitudes

    Arch Pediatr Adolesc Med

    (2005)
  • J. Leask

    How do general practitioners persuade parents to vaccinate their children? A study using standardised scenarios

    N S W Public Health Bull

    (2009)
  • H. Waitzkin

    On studying the discourse of medical encounters. A critique of quantitative and qualitative methods and a proposal for reasonable compromise

    Med Care

    (1990)
  • Cited by (75)

    • Clinician Communication to Address Vaccine Hesitancy

      2023, Pediatric Clinics of North America
    View all citing articles on Scopus
    View full text