Strengthening Vaccine Confidence and Acceptance in the Pediatric Provider Office

Vaccine Confidence and Acceptance in the United States

Vaccines are among the greatest medical and public health achievements, resulting in substantial reductions in morbidity and mortality; between 1994 and 2013, an estimated 300 million illnesses and 700,000 deaths have been prevented through childhood immunization in the United States.¹ Overall vaccine coverage is high, with nearly 99% of children in the US having received any vaccines by age 2 years, and more than 94% of kindergartners having received vaccines against measles, mumps, rubella, varicella, diphtheria, tetanus, and pertussis.^2,3 Although most parents in the US accept vaccination for their children, vaccine hesitancy leading to the delay or refusal of all or some vaccines is a growing concern. More than one-third of young children in the US receive vaccines on a timeline or pattern inconsistent with the recommended schedule.⁴ In addition, rates of vaccine exemptions have risen slightly for kindergartners in recent years.³ The resurgence in measles, driven by pockets of undervaccinated communities with high levels of vaccine hesitancy, is further evidence of the need for strengthening vaccine confidence.⁵

Vaccine hesitancy encompasses the delay in acceptance or refusal of vaccination despite availability of vaccination services.⁶ However, it is not limited to only vaccination behaviors, but also the state of doubt of indecision around vaccination, as some parents who accept vaccination for their children still harbor concerns about vaccines.^7,8 Vaccine attitudes represent a continuum, from complete refusal to active demand for vaccines, with most who are vaccine hesitant falling somewhere in the middle.⁹ The reasons for vaccine hesitancy are complex, with many contextual, individual, and vaccine-specific factors.⁶ These range from beliefs that vaccines are unnecessary because the child is not at risk for disease or the disease is not dangerous; concerns about vaccine safety; concerns about too many vaccines at once, perceived as overwhelming the immune system and also creating patient discomfort from multiple shots at once; preferences for natural products and immunity; distrust in government and the vaccine industry; or concerns about encroachments on individual liberties.^10–12

Because of these challenges, the Centers for Disease Control and Prevention (CDC) and its partners recently launched the “Vaccinate with Confidence” strategic framework to strengthen vaccine confidence.¹³ The three core components of this framework include protecting communities by using every available tool to find and protect communities at risk using tailored, targeted approaches; empowering families to make the decision to vaccinate by strengthening parent-provider vaccine conversations and fostering a culture of immunization in the provider's practice; and stopping vaccine myths by working with local partners and trusted messengers and educating key stakeholders about vaccines.

Pediatric providers play a critical role in strengthening vaccine confidence, particularly in empowering families to make the decision to vaccinate. Although little evidence on effective interventions for reducing vaccine hesitancy exists,^14–17 several practical communication and organizational approaches have been identified to increase vaccine acceptance. In this review, we summarize the evidence for potential strategies to increase vaccine acceptance and strengthen vaccine confidence in the pediatric provider's office.

Communicating About Vaccines

When communicating about vaccines, the person delivering the message, the timing of the conversation, and how the message is presented are all important factors for consideration. Health care providers are consistently rated as the parent's most trusted source of vaccine information, and reassurance or information from a health care provider is the leading reason that parents who initially planned to delay or refuse vaccines change their mind to acceptance.^18,19 It is therefore essential that all staff in the pediatric practice, from the receptionist to medical assistants, nursing staff, physicians, and office managers, provide consistent messages about the importance of vaccination. Health care providers, who themselves are confident in vaccines, are more likely to recommend vaccination to their patients, although not all feel prepared to direct these discussions.²⁰ Thus, it is important that health care providers have up-to-date information on vaccine recommendations, access to clinical resources on vaccinations, and answers to their own vaccine questions for better vaccine communication and education with families.

Part of this whole-team approach to vaccine communication involves building trust between patient or parent and the health care provider or system. Trust is a fundamental component of vaccine decision-making, as it can both positively or negatively influence vaccine acceptance.^11,21–23 Trusted providers are described as those who project a caring disposition; spend time with the patient; listen to, acknowledge, and address questions and concerns; demonstrate competency of scientific information, and use a whole-person approach by treating the patient as an individual.^21,24,25 It is also important for providers to recognize the role of historical or systemic inequities toward certain groups, such as African Americans, and how they may relate to patient trust overall as well as toward vaccines.²³ In the pediatric setting, building trust early with parents of young infants is important, as satisfaction among these parents is associated with overall improved health care utilization and vaccine uptake.²⁶

Although many pediatric providers will meet the parents of their patients for the first time during the postnatal period, evidence suggests that the prenatal period may be a critical time as most mothers make vaccine decisions for their child before or during pregnancy.^27–30 In addition, parents who refuse vaccines for their child are more likely to start thinking about vaccination before their child is born compared with those who accept vaccines.²² Despite the desire for more information on pediatric vaccines from a health care provider, expectant mothers often have limited opportunities to have these discussions and frequently turn to the internet, media, or word of mouth for information.^31,32 Most expectant mothers hold positive beliefs toward vaccination, although the intent to delay or refuse vaccines among some suggest that more opportunities to engage with providers around pediatric vaccines would be useful.²⁹ Thus, proactive approaches to initiate vaccine conversations early during the prenatal period, either at obstetric visits, prenatal classes, prenatal pediatric conferences, or in the early postnatal period, may be important for promoting vaccine confidence and acceptance.^33,34

When initiating vaccine conversations with parents, a strong recommendation using a presumptive approach has been demonstrated to be 3- to 5-fold more effective than a participatory approach in increasing vaccine acceptance, even after adjusting for baseline parental vaccine hesitancy.^35–39 A provider using the presumptive (directive) approach may say “Joe is going to get vaccines to protect against seven diseases today: diphtheria, tetanus, whooping cough, rotavirus, Haemophilus influenzae, pneumococcal disease, and polio,” instead of a participatory (conversational) approach such as “what do you want to do about Joe's shots today?” In general, parents are satisfied with the presumptive approach, although there may be differences between parents of young children and adolescents. For example, although one study among parents of young children demonstrated reduced parental satisfaction with the presumptive approach, several studies of parents of adolescents demonstrated comparable levels of satisfaction with either the presumptive or participatory approaches.^35,36,38 Among parents of adolescents, receipt of a strong recommendation for human papillomavirus vaccine (HPV) was associated with greater perceived urgency for vaccination, greater trust in the information received from the provider, and decreased vaccine hesitancy measures.³⁵ In addition, the continued use of the presumptive approach over time is associated with ongoing benefits, as repeated exposure to presumptive vaccine recommendations at two or more visits resulted in continued greater vaccine acceptance.⁴⁰

Even with a strong recommendation, many parents still have questions or doubts regarding vaccines, including those parents who ultimately go on to accept vaccination for their child.⁸ Many of them are simply looking for additional information or reassurance before making the decision to vaccinate.¹⁹ In fact, among parents who initially resist a vaccine recommendation delivered through a presumptive approach, approximately one-half accept vaccines when the provider pursues their initial recommendation.³⁷ When addressing specific concerns, conveying both scientific information as well as personal experience with vaccines and vaccine-preventable diseases can be useful.^41,42 Pediatricians report that sharing their experiences vaccinating their own children as well as with vaccine safety in their own practice are the most effective ways to promote vaccine acceptance among parents who are hesitant.⁴³ In addition, parents who have concerns about vaccines desire balanced information about both the risks and benefits.²¹ Strong messaging that overly minimizes risk can paradoxically lead to an increased perception of vaccine risk among parents.⁴⁴ It is also important to use care when countering vaccine myths to avoid the unintended consequence of reinforcing the myth, which can lead to reduced intention to vaccinate.^45–47 Emphasizing the facts without repeating the myth, providing an alternative explanation for the stated myth, and providing additional resources or references to support the provider's explanation can all be helpful in addressing vaccine myths.⁴⁸ However, many pediatricians express considerable barriers to effectively communicating with parents who continue to have vaccine concerns, frequently citing lack of time, competing priorities, as well as the belief that continued discussions are unlikely to change the parent's mind or that parents would not understand the risk/benefit information.⁴³

One promising area in vaccine communication that may help address these challenges is the use of motivational interviewing. This approach is based on the guiding principles of asking open-ended questions to better understand an individual's responsiveness to change; acknowledging, listening, and summarizing concerns; and after seeking permission, advising, and responding to concerns.⁴⁹ Through motivational interviewing, the provider expresses understanding of the parent's knowledge and beliefs, elicits discrepancies between the current situation and what the parent desires, allows the parent to explore their own views, and supports the parent's confidence in their ability to change. Providers who received training in motivational interviewing techniques reported that it improved their communication with parents who are vaccine hesitant and helped increase vaccine acceptance; in addition, parents have expressed satisfaction with this intervention.^50,51 For example, use of the presumptive approach followed by motivational interviewing with parents who demonstrated HPV hesitancy was associated with a nearly 10% increase in HPV initiation and 4% increase in HPV series completion rates.⁵² An educational intervention using motivational interviewing of parents in maternity wards during the postpartum period led to increases in the intention to vaccinate as well as a 7% increase in infant vaccination coverage at age 7 months and 9% increase in up-to-date status by 2 years.^33,50,53,54

Creating a Culture of Immunization in the Practice

Creating a culture of immunization in the clinical setting involves ensuring that all staff members are engaged with, and office practices are conducive to, supporting parents in their decisions to vaccinate. Building upon potential communication strategies to strengthen vaccine confidence and acceptance, some evidence for practice-level approaches exists and the CDC has developed resources to help providers develop this organizational culture (Table 1).⁵⁵ Although data specifically among populations that are vaccine hesitant are limited, these approaches may help emphasize vaccination as the norm with broad support from all staff members in the office/clinic, as well as improve efficiency in vaccination and optimize overall uptake in the practice. Several strategies can be implemented to help ensure that children receive timely vaccinations and stay up to date, including reminder or recall systems, standing orders, and providing educational resources (Table 2).

Table 1. Strategies to Foster a Culture of Immunization in the Practice and Improve Provider-Patient Vaccine Conversations

Table 2. Selected Resources for Strengthening Vaccine Confidence and Acceptance

Reminder or recall systems are used as a tool for ongoing communication with parents between their child's appointments to make sure the child stays on schedule with vaccination. Use of these systems has been demonstrated to be effective in improving vaccination rates, whether used alone or in conjunction with other interventions, regardless of the type or sophistication of the system (eg, electronic, paper-based), and in a range of settings and populations.⁵⁶ However, only 16% of pediatric practices use reminder/recall systems, primarily due to logistical or financial barriers in implementation.⁵⁷ Use of centralized messages, for example from a health department or managed care organization rather than an individual practice, may help remove some of these barriers to implementation of patient reminder and recall systems. Centralized reminder/recall messages from health departments using vaccination records in the state immunization information system (IIS) has been demonstrated to be effective in increasing vaccination rates and further supports the importance of ensuring that vaccination records are entered into the IIS.⁵⁸ Furthermore, forecasting tools (eg, alerts in the electronic medical record or IIS) help providers automatically determine which vaccinations a patient needs at that time. These tools have been demonstrated to improve vaccination rates.⁵⁹ In addition, assessing the patient's vaccination record at each visit can help reduce missed opportunities for vaccination, which are common among children and adolescents.^60,61

The use of standing orders is another tool for optimizing vaccination acceptance and efficiency. Standing orders allow nurses, pharmacists, and other trained health care personnel, by state law, to assess a patient's immunization status and administer vaccinations according to a protocol approved by a physician or other authorized practitioner and have been demonstrated to improve vaccination rates.^62–64 Despite this evidence, only 59% of pediatricians report using standing orders. Concerns about vaccine errors, beliefs about patient preferences for vaccine discussions, and the role of the physician in making vaccine recommendations are the leading reasons for nonadoption of standing orders.⁶⁵ Although the acceptability of standing orders has not been evaluated among parents who are vaccine hesitant, this approach may help to further emphasize vaccination as the norm, and still leaving the possibility open for further, more in-depth conversations with the physician.

Providing educational materials also may be useful in supporting parents' vaccine decisions and optimizing vaccine acceptance and efficiency in the clinical setting. Although the evidence overall is mixed, effectiveness of this type of parent-centered educational intervention on parental vaccine intentions have been described in several studies and may be most useful when tailored to the specific concern of the parent such as vaccine safety.^14,16,32 Furthermore, although most parents report receiving the federally required vaccine information statement (VIS), only 60% receive it each time prior to their child's vaccine administration.⁶⁶ Most parents who have the opportunity to read the VIS and ask questions in advance report some usefulness in the material. In contrast, parents with reduced vaccine confidence report lower satisfaction, although these parents are also less likely to have had the opportunity to read and discuss the information in VIS. Thus, improving both the availability and timeliness of tailored educational materials and the VIS may be useful in supporting parents' vaccine decisions.

When a Parent Refuses Vaccines

A parent may refuse some or all vaccines despite the pediatrician's best efforts to communicate effectively and provide resources to help support the parent's vaccine decisions. Approximately one in five pediatricians report always or often dismissing families who refuse vaccines from their practice, although this approach is controversial with little evidence for the effect of these decisions on the patient.^67,68 Pediatricians may be uncertain on the next steps to continuing to provide care for the patient despite vaccine refusal. In this situation, trying to convince or pressure the parent in the moment may lead to an adversarial position and further loss of trust.⁶⁹ Maintaining rapport with the parent and leaving the door open for future discussion can provide additional opportunities to discuss the importance of vaccines. Before the patient leaves the office, creating at least one action item, such as scheduling the next visit or providing tailored information to address the parent's questions, may be helpful in maintaining the open dialogue that may result in future vaccine acceptance.

Conclusion

Vaccine hesitancy is a complex and growing challenge facing pediatric providers in the US. Although there is limited evidence for best practices to address vaccine hesitancy in the provider office, specific communication strategies (ie, using a whole-team approach, recommending vaccines presumptively, incorporating motivational interviewing) and organizational methods (ie, reminder/recall systems, standing orders, providing educational materials) help foster a culture of immunization and improve vaccine uptake and efficiency in clinical practice. These communication strategies and organizational methods will likely take on increased significance as the development, implementation, and evaluation of the coronavirus disease 2019 vaccines continue to unfold.