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