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Provider-parent Communication When Discussing Vaccines: A Systematic Review
Journal of Pediatric Nursing xxx (2016) xxx–xxx
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Journal of Pediatric Nursing
Provider-parent Communication When Discussing Vaccines: A Systematic Review1 John T. Connors, MSN, FNP-C ⁎, Kate L. Slotwinski, MSN, PMHNP-BC, Eric A. Hodges, PhD, FNP-BC University of North Carolina, School of Nursing, Carrington Hall, CB #7460, Chapel Hill, NC 27599-7460, United States
a r t i c l e
i n f o
Article history: Received 12 September 2016 Revised 17 October 2016 Accepted 7 November 2016 Available online xxxx Keywords: Provider interaction Vaccination Vaccine hesitant Communication
a b s t r a c t Problem: Expert literature on communication practices with vaccine hesitant parents posits that a nonconfrontational/participatory discussion with the parent would be the best approach to improve compliance. A prior literature review found limited evidence to recommend any particular face to face intervention other than to incorporate communication about vaccination effectiveness during an encounter. Hence, a systematic review was performed in an attempt to determine the most efficacious communication practices to use with parents with vaccination concerns. Eligibility Criteria: Quantitative and qualitative studies written in English that assessed the communication framework/style of the provider-parent interaction and studies where provider communication was listed as an intervention were reviewed. Sample: Nine articles were included in the sample. Results: The majority of the studies were descriptive and qualitative in nature with only one randomized controlled trial. Five of the 9 studies utilized a descriptive cross-sectional design. Two main themes included message types recommended or given by the provider and message types that were requested by the parent. Conclusions: Overall, findings showed that there is currently not enough information to definitively state the type of provider-parent communication style that should be employed to affect the parents' vaccination viewpoint. However, recurring themes of trust in the provider and a personalized provider-parent interaction were evident, which promotes a participatory type of interaction. Implications: The literature indirectly supports providers engaging with vaccine hesitant parents in a more individualized, participatory format, though higher quality and more rigorous studies that focus specifically on provider-parent communication practices are needed. Published by Elsevier Inc.
1. Background Parental concerns about childhood vaccinations have been shown to lead to vaccination hesitancy (VH), which places children at risk of not receiving the recommended vaccines by either being on an alternative vaccination schedule or forgoing specific vaccinations altogether. In a review by Dube et al. (2013), parental VH was defined as a parental attitude towards vaccination that is associated with overall increased under-vaccination of children and influenced broadly by “emotional, cultural, social, spiritual, political… [and] cognitive factors” (p. 1764). At an individual level, an identified vaccine hesitant parent runs the continuum from full vaccine compliance to near complete vaccine refusal and may request to employ an alternative vaccination schedule. Studies show that between 10% to 25% of parents utilize an alternative vaccination schedule (Dempsey et al., 2011; Nadeau et al., 2015). The 1 This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. ⁎ Corresponding author. E-mail addresses: [email protected], [email protected] (J.T. Connors).
significant number of parents choosing to utilize an alternative vaccination schedule or forego certain vaccinations is increasing (Freed, Clark, Butchart, Singer, & Davis, 2011; Glanz et al., 2013), which indicates that VH is a growing problem that places unvaccinated children at increased risk for contracting vaccine preventable diseases (VPD). This is especially problematic as provider tolerance of vaccine hesitant parents is decreasing, and parents that are not amenable to having their children vaccinated as currently recommended may gravitate towards more tolerant medical practices; thereby potentially exacerbating the magnitude of VPD outbreaks (Buttenheim, Cherng, & Asch, 2013). It is widely recognized that the interaction between providers and parents when discussing parental vaccination concerns is important in helping to alleviate parental concerns. Gust, Darling, Kennedy, and Schwartz (2008) investigated the main cause as to why vaccine hesitant parents reversed their decision about delaying or refusing a vaccine for their child and found the biggest contributing cause was the health care provider offering information about vaccines. However, providers seem to be increasingly non-tolerant of vaccine hesitant parents and less willing to discuss parental vaccination concerns (Leib, Liberatos, & Edwards, 2011).
http://dx.doi.org/10.1016/j.pedn.2016.11.002 0882-5963/Published by Elsevier Inc.
Please cite this article as: Connors, J.T., et al., Provider-parent Communication When Discussing Vaccines: A Systematic Review, Journal of Pediatric Nursing (2016), http://dx.doi.org/10.1016/j.pedn.2016.11.002
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Expert literature pertaining to communication practices with vaccine hesitant parents supports the importance of the health care provider-parent interaction. This literature posits that a nonconfrontational discussion and having honest communication with the parent would be the best approach (Healy, 2014; Schwartz, 2013; Tenrreiro, 2005). A systematic review by Kaufman et al. (2013) found limited evidence validating that face-to-face interventions (defined as individual counseling to multi-session interventions) led to increased vaccination rates in unimmunized children. Also, Kaufman et al. reported there was insufficient evidence to recommend any particular type of face to face intervention other than to incorporate communication about vaccination effectiveness during a clinical encounter. However, this systematic review was limited to evaluating only randomized controlled trials (RCT) up to 2012 and did not elucidate any specific communication practices that might increase vaccine uptake. Currently the American Academy of Pediatrics (2012) and the Centers for Disease Control and Prevention (2012) recommend a more collaborative/participatory discussion (listening attentively, welcoming questions, respecting parental authority) when dealing with parental vaccination concerns. However, no systematic reviews of the most efficacious communication practices (practices that may decrease parental vaccine hesitancy and increase the likelihood that vaccination will occur) were found; nor did the most recent review by Kaufman et al. (2013) identify any beneficial discussion frameworks when dealing with parental vaccination concerns. Therefore, a systematic review was performed to answer the following questions: Among parents with vaccination concerns, does a collaborative/participatory discussion between the provider and parent affect the parent's viewpoint on vaccination compared to other interaction types? Also, what are the most efficacious communication practices to use with parents when discussing vaccines? 2. Methods The literature search for this systematic review was performed using the National Library of Medicine (PubMed) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Major search terms were used to create search algorithms. The search algorithm used for both PubMed and CINAHL was as follows: (Provider OR Physician OR Nurse Practitioner OR Physician Assistant OR Pediatrician) AND (Parents OR Parent OR Guardian OR Mother OR Father) AND (Clinic Visit OR Communication OR Relationship OR Interaction OR Discussion OR Participatory OR Presumptive) AND (Vaccine Hesitancy OR Vaccination Hesitancy OR Non Vaccinating OR Vaccine Resistant OR Not Vaccinated). Articles were limited to studies involving humans and published from March 2011 to March 2016 in English. The limitation to articles published in the past five years was to ensure up-to-date information was included in the study and to exclude overlap from a prior systematic review that examined provider-parent face to face interactions. These searches resulted in 41 articles from the PubMed and CINAHL databases, which were transcribed from the RefWorks online citation management database into Covidence (2015) systematic review software for further review and analysis (Fig. 1). Exclusion criteria for full text review included: manuscripts not containing any primary data (expert opinion/individual article reviews), provider-parent communication was not assessed, and studies that were performed in developing countries where access to vaccines is a greater issue than parental concerns about vaccines (as there is a lack of vaccine availability and limited healthcare infrastructure). Inclusion criteria for full text review included: the communication framework/ style of the provider-parent interaction was investigated and/or communication practices were identified that may decrease parental vaccine hesitancy and increase the likelihood that vaccination will occur. Two reviewers independently reviewed the titles and abstracts of all publications produced by the initial search utilizing Covidence (2015) systematic review software. Any conflicts between reviewers were
resolved through discussion and consensus. A total of three conflicts were resolved by these means. Full-text review was performed by one reviewer with confirmation of the appropriateness to include into the sample by a second reviewer. Data extraction and a quality analysis were performed by one reviewer. Data extracted included communication practices, discussion and interaction type (participatory vs. other), the number of subjects included, study design, and the outcomes/findings (where appropriate) that pertained to communication practices and/or the interaction type. The quality of the evidence was analyzed by using the Cochrane criteria for assessing risk of bias (Higgins & Green, 2011) as well as the Melnyk and Fineout-Overholt (2011) tool for assessing the level of evidence. Conventional content analysis as described by Hsieh and Shannon (2005) was then used to organize, analyze, and interpret data from extracted information that fit under the broad a-priori headings of communication practices and discussion and interaction type(s). Numerous subcategories were identified under the broad a-priori headings and were able to be consolidated into a smaller number of categories. The use of conventional content analysis was seen as appropriate due to the limited amount of literature on the subject being investigated. 3. Results Forty total abstracts were reviewed with 15 excluded due to not meeting criteria. A total of 25 articles was subjected to a full text review with 16 being rejected for reasons (see Fig. 1) that included but were not limited to: the provider-parent communication was not assessed, the article was solely based on expert opinion, and the article was a review of another article. Nine articles met criteria to be included in the review. Extracted data was wide ranging due to the overabundance of qualitative studies in this synthesis. The level of the evidence overall was very low (see Table 1) based on the Melnyk Pyramid for evaluating the level of evidence (Melnyk & Fineout-Overholt, 2011). The overwhelming majority of the studies were descriptive and qualitative in nature with only one randomized controlled trial. Five of the 9 studies utilized a descriptive cross-sectional design. Additional study designs utilized were qualitative and employed observational methods and focus groups. Sample sizes ranged from n = 21 to n = 575, with 4 studies having sizes under 100. Studies were primarily limited to distinct homogenous populations (i.e. Hispanic, Caucasian, and African American) in outpatient clinics in discrete geographical locations (Canada, Denmark, the Netherlands, and suburban and inner city clinics in the U.S.). Taking the above information into account and applying the Cochrane criteria for assessing for risk of bias (Higgins & Green, 2011), the risk of bias and a possible lack of generalizability was noted to be high (see Table 1 for specific findings). Only 2 of 9 articles directly examined specific types of providerparent interactions during conversations about vaccines or utilized a specific provider-parent communication framework and measured the subsequent effect on the parental view of vaccination (Henrikson et al., 2015; Opel et al., 2013). One study that directly examined the type of provider-parent interaction with a provider-parent discussion framework, consisted of a presumptive (“we have to do some shots”) vs. a participatory (invite parental questions, use open ended questions) interaction (Opel et al., 2013). Another study utilized a more participatory framework during the provider-parent interaction (Henrikson et al., 2015). The results from the study performed by Henrikson et al. showed that a more participatory type of conversation framework did not have any effect on parental VH. However, the authors note that providers enrolled in the interventional arm of the study may not have been properly trained, and providers may not have been blinded to which arm of the study they were enrolled. The study performed by Opel et al. examined the use of a participatory vs. a presumptive discussion format when recommending vaccination in a study consisting of 111 participants. The study found that a larger proportion of parents initially resisted vaccine recommendations
Please cite this article as: Connors, J.T., et al., Provider-parent Communication When Discussing Vaccines: A Systematic Review, Journal of Pediatric Nursing (2016), http://dx.doi.org/10.1016/j.pedn.2016.11.002
Identification
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Records identified through database searching PubMed (n=35)
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Additional records identified through CINAHL (n=6)
Included
Eligibility
Screening
Records after duplicates removed (n=38)
Records screened (n=38)
Records excluded (n=15)
Full-text articles assessed for eligibility (n=23)
Full-text articles excluded, with reasons (n=14)
Studies included in synthesis (n=9)
- 7 Wrong study design (expert opinion papers or non-scholarly). - 1 Wrong intervention - 1 Wrong outcomes - 3 Type of providerparent communication not assessed - 2 Secondary source of information/primary source article included in current sample
Fig. 1. Prisma flow diagram. Note: Adapted from Moher D., Liberati A., Tetzlaff J., Altman D. G., The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and MetaAnalyses: The PRISMA Statement. PLoS Medicine 6(6): e1000097. doi:10.1371/journal.pmed1000097.
when providers used a participatory rather than a presumptive format. However, it was noted that the majority of the providers involved in the research did not elicit parental concerns prior to the provider-parent encounter, nor was it clear that a therapeutic relationship existed between the provider and the parent. Based upon the results of the only two studies found that investigated specific types of provider-parent interaction frameworks, this review took a more general approach to glean efficacious components of the provider-parent interaction when discussing vaccines. Data extracted in this review can be categorized as either the communication practices associated with the provider or the type of message requested by the parent.
Mollema et al., 2012). Provider flexibility with parental decisions on when vaccines will be given [flexibility was identified as a factor to help parents choose to vaccinate] (Mollema et al., 2012) as well as involving the parent in the vaccination process [allowing parents to hold their child while a vaccine is being administered] were seen as essential (Kempe et al., 2015). A single study found that pursuing a vaccination recommendation in a parent that is initially resistant is beneficial (Opel et al., 2013). Additionally, the study by Opel et al. (2013) found that provider-parent interactions about vaccines are able to be placed in either a presumptive or participatory format with the participatory format being associated with greater odds of initial parental resistance to vaccination.
3.1. Communication Practices Pertaining to the Provider 3.2. Message Type Requested by the Parent Provider themes included: tailoring information to specific parent concerns (McRee, Gilkey, & Dempsey, 2014), utilizing a screening tool to identify specific concerns [a majority of providers felt that a screening tool would be helpful] (McRee et al., 2014), and showing respect and empathy towards parental concerns [the doctor works with parents to ensure vaccination occurs and gives praise afterwards; affording respect and empathy towards vaccine hesitant and vaccine resistant parents] (Elverdam, 2011; Mollema, Staal, Van-Steenbergen, Paulussen, & De-Melker, 2012). Additionally, developing trust prior to discussing vaccination concerns [allopathic physicians seen as trusted sources of information; developing a trusting relationship first prior to discussing vaccination] was seen as important (Busse, Walji, & Kumanan, 2011;
Some general themes extracted from the parents' perspective included: the provider should discuss any specific diseases prevented/ negative sequelae and give a strong recommendation for vaccination [discussion limited to HPV vaccination] (Alexander et al., 2014), a primary concern for parents was safety (Busse et al., 2011), and discussing the need for vaccination was seen as being predictive of receipt of the vaccination (Hofstetter, Barrett, & Stockwell, 2015). Additionally, parents stated that their choice to vaccinate (or not vaccinate) affected the provider-parent relationship and introduced conflict if the provider was not willing to discuss parents' vaccination concerns (Busse et al., 2011).
Please cite this article as: Connors, J.T., et al., Provider-parent Communication When Discussing Vaccines: A Systematic Review, Journal of Pediatric Nursing (2016), http://dx.doi.org/10.1016/j.pedn.2016.11.002
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Table 1 Article review table. Citation
Sample
Study design and level of evidencea
Results
Study limitations
1. Alexander et al., 2014, USA
n = 21
Qualitative research design with semi-structured interviews (VI)
1. Clinical message given by the provider should include specific diseases prevented by the HPV vaccine, a discussion of the sexual nature of HPV, and a strong recommendation for adolescent males to receive the vaccine. 2. Commercial message given should be fear based. 1. Parents needing unbiased resources regarding vaccinations. 2. Physicians were seen to be biased sources of information by providing only pro-vaccine or incomplete information regarding parental concerns. 3. Many respondents most commonly endorsed both their allopathic and naturopathic physicians as trusted information resources; though only 15.8% of parents identified an allopathic physician as the most trusted source of information. 4. Parents were concerned with vaccine safety. 5. Parents (17.3%) noted that discussing vaccine choices (to vaccinate or not vaccinate) introduced conflict into the relationship. 1. The provider minimalizes the pain from the injection “... small pinprick”. 2. The doctor notes that he/she reluctantly does them. Doctors raising their voices when discussing vaccine side effects. 3. The provider and the parent conspire/work together to ensure the vaccination occurs. 4. The end of the vaccination is emphasized and praising of the child occurs. 5. The doctor talks about the harm he/she has done to the child due to the pain caused by the injection. 1. Fewer physicians in the intervention (Ask, Acknowledge, Advise) group reported high confidence in talking about risks (58% vs. 70%, p = 0.06), providing information (69% vs. 81%, p = 0.03), and answering difficult parent questions (54% vs. 69%, p = 0.01). 2. After adjusting for baseline self-efficacy, the intervention had no effect on physician self-efficacy or on parental vaccine hesitancy. 1. Caregivers who reported discussing receipt of the influenza vaccination with a provider were more likely to know their child needed two doses (55% vs.35%, p b 0.05) and have a fully vaccinated child (11% vs. 0%, p b 0.05).
1. Small sample size, study design, and primarily Hispanic and African American sample limits generalizeability. 2. Sample consisted of primarily non-vaccine hesitant parents.
2. Busse et al., n = 95 2011, Canada
Descriptive, cross-sectional (VI)
6. Elverdam, 2011, Denmark
Qualitative, observational (VI)
n = 25
7. Henrikson n = 347 et al., 2015, USA
Randomized controlled Trial (II)
8. Hofstetter n = 128 et al., 2015, USA
Descriptive cross-sectional design (VI)
9. Kempe et al., n = 534 2015, USA
Descriptive, cross-sectional (VI)
10. McRee et al., 2014, USA
n = 575 Descriptive, cross-sectional survey (VI)
11. Mollema et al., 2012, Netherlands
n = 25
Descriptive, qualitative study utilizing focus groups (VI)
1. Small sample size and study design limits generalizeability. 2. The questionnaire used only has face validity.
1. Small sample size and study design limits generalizeability. 2. Procedures are not explicitly stated and are discussed in generalities. 3. Performed on relatively non-vaccine hesitant population in Denmark.
1. Clinics may have been aware of being in the control vs. intervention arm after baseline data was gathered. 2. Providers may not have been completely trained at intervention site. 3. Power calculation performed with recommendation of a sample size of 500.
1. A convenience sample was used. However, bias may have been introduced as participants were drawn from another study that had an interventional (education on influenza) and control arm. 2. The survey/questionnaire was designed based upon expert opinion and prior studies. 3. The sample consists of primarily Hispanic families and may limit generalizability. 1. Telling parents that you think it is more painful for 1. No power analysis and no discussion of adequate their child to come back for multiple visits for shots sample size. rather than get them all at once. 44% FP and 53% 2. Procedures to transcribe, analyze data were not Peds (p = 0.15) stated that they do this and 10% FP explicitly stated. and 8% Peds (p b 0.0001) state that very effective. 3. Results are provider opinions on interventions to 2. Involving the parent in vaccine administration increase parental compliance with vaccination. (having the parent hold the child). 55%FP and 45% Peds (p = 0.003) stated that they do this and 17%FP and 11% Peds (p b 0.005) state that very effective. Provider strategies that were reported to be helpful 1. The total number of respondents to the questionnaire was 615 and only 575 were used. No explanation was given as to why some participant 1. Tailoring information to specific parent concerns responses were not included. (74%) or to parents' background (68%). 2. There is no discussion/justification of the sample 2. Providing information about HPV vaccine to parents size. No power analysis was performed. The particprior to the clinical visit (72%). ipation rate was noted to be small (16%). 3. Over half of providers felt that it would be helpful to have a screening tool to identify specific parental concerns (58%). 1. The sampling method might have selected a 1. Providers showing respect and empathy towards predominance of childhood vaccine providers with vaccine hesitant (VH)/vaccine resistant (VR) a positive attitude towards vaccines. parent(s) were identified themes. 2. Providers developing a trusting relationship with the VH/VR parent(s) first prior to discussing vaccination was another identified theme.
Please cite this article as: Connors, J.T., et al., Provider-parent Communication When Discussing Vaccines: A Systematic Review, Journal of Pediatric Nursing (2016), http://dx.doi.org/10.1016/j.pedn.2016.11.002
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Table 1 (continued) Citation
12. Opel et al., 2013, USA
a
Sample
Study design and level of evidencea
n = 111 Cross-sectional, observational (VI)
Results
Study limitations
3. An anthroposophical view was that the providers' task is to inform patients well; thereby allowing a parent to make a decision with that information. 4. Flexibility was identified as another factor to help parents to make a decision/choose how immunizations are given. 1. A larger proportion of parents resisted vaccine 1. The Hawthorne effect is a consideration as the recommendations when providers used a providers and parents were being videotaped. participatory rather than presumptive initiation format 2. Vaccine hesitant parents intentionally oversampled (83% vs. 26%; p b 0.001). This finding remained true leading to a higher risk of bias. among VH parents (89% vs. 30%; p b 0.001). 3. The rationale and potential side effects of vaccines 2. Pursuing a vaccination recommendation in a parent were not given to parents more often during first that is initially resistant may be beneficial. time vaccination conversations.
II = One or more RCTs; VI = single descriptive or qualitative study. (Melnyk & Fineout-Overholt, 2011).
4. Discussion In general the studies included in the sample were not directly comparable to one another as they were primarily qualitative in nature with varying study designs. This was unexpected, though not surprising, as researchers are currently exploring interaction types and communication processes that affect the vaccine hesitant parent's viewpoint on vaccination. Studies included in this review in some instances were limited to examining the uptake of a specific vaccine. As such, our ability to synthesize study outcomes and utilize a framework to grade the quality of the evidence was limited. However, some general discussion guidelines and findings from the provider or parent perspective can be elucidated with the understanding that the overall quality of the evidence is very low, which was determined by using the Cochrane criteria for assessing risk of bias (Higgins & Green, 2011) as well as the Melnyk and Fineout-Overholt (2011) tool for assessing the level of evidence. This systematic review of the literature showed that there is not currently enough information to definitively state the type of providerparent interaction that should be employed. However, extracted data placed under the headings of communication practices pertaining to the provider and the message type requested by the parent were able to be further categorized and synthesized. The findings of this review that having trust in the provider is important with regards to vaccination (Busse et al., 2011; Mollema et al., 2012) is further supported by a qualitative study performed by Benin, Wisler-Scher, Colson, Shapiro, and Holmboe (2006) who found that trust in the provider was found to be pivotal for a mothers' decision to vaccinate their child. Other studies show that parental trust in the provider is essential to ensure vaccination compliance (Gust et al., 2008; Smith, Kennedy, Wooten, Gust, & Pickering, 2006). The additional findings in this review also support the building of parental trust in the provider (as put forth by Benin et al., 2006) when taking into account the individual components of building trust. Specifically, Benin et al. found that a mothers' trust is gained when a provider spends time discussing vaccines, is knowledgeable about parents' vaccination concerns, offers satisfactory answers to parent questions, uses a patient centered approach, and does not deride parents' concerns. The identified themes of having a personalized provider-parent interaction (Alexander et al., 2014; Busse et al., 2011; Elverdam, 2011; McRee et al., 2014) and discussing the need for scheduled vaccinations (Hofstetter et al., 2015; Kempe et al., 2015; Opel et al., 2013) can be viewed as a means to helping build trust. Benin et al. also noted that the competence of the provider in dealing with parental vaccination concerns is linked to building parental trust in the provider. According to Mechanic (1998) and Thom, Hall, and Pawlson (2004) the competence of the provider consists of connecting both technical and interpersonal competence where the provider has the required knowledge and judgment to inform and treat a patient as well as the ability to communicate effectively. Extracted data from this review
supports providers having technical competence under the themes: discussing the need for scheduled vaccinations with the parent (Hofstetter et al., 2015; Kempe et al., 2015; Opel et al., 2013), and utilizing a screening tool to identify specific concerns (McRee et al., 2014). Competence in communication is implicit in many of the themes identified from this review and include: tailoring information to specific parent concerns (McRee et al., 2014), giving a strong recommendation for vaccination (Alexander et al., 2014), showing respect and empathy towards parental concerns (Elverdam, 2011; Mollema et al., 2012), and pursuing a vaccination recommendation in a parent that is initially resistant (Opel et al., 2013). The specific finding by Opel et al. (2013) of a presumptive approach (“we have to do some shots”) instead of a participatory interaction (invite parental questions, use open ended questions) being associated with decreased parental resistance to the provider recommendation to vaccinate does not support the current communication recommendations as put forth by the Centers for Disease Control and Prevention (2012) and Prevention and the American Academy of Pediatrics (2012). Though Opel et al. acknowledged that a participatory interaction helps develop trust with establishing a therapeutic relationship over time, it may well be beneficial to initiate the vaccination recommendation in more of a presumptive format when examining a provider-parent initial interaction regarding vaccine recommendations if other factors are not taken into consideration. Also, when taking into account the potential longitudinal effects of patient trust and perceived competence of the provider, it may be helpful to identify any vaccination concerns prior to the encounter to determine if a more participatory discussion format would be warranted vs. a presumptive or other type of format or conversation framework. Hence, deeper understanding and further research is needed on the effects of the style of the provider parent interaction, preferably taking into account measurements of trust, competence in the provider, and eliciting any parental vaccination concerns prior to offering a vaccination recommendation. 5. Limitations Limitations of this systematic review include a paucity of high quality data that is directly comparable. Thus, broad categories had to be developed for data extraction and the development of themes. This likely provides an incomplete picture of the provider parent interaction and communication processes and only affords what would be considered low quality evidence for incorporation into clinical practices. Future, higher quality and more rigorous studies that focus specifically on provider-parent communication practices should be performed, as currently identified studies are primarily qualitative and descriptive in nature. Also, many of the studies included in this review were limited to distinct homogenous populations (i.e. Hispanic, Caucasian, and African American) in outpatient clinics in discrete geographical locations (Canada, Denmark, the Netherlands, and suburban and inner city clinics
Please cite this article as: Connors, J.T., et al., Provider-parent Communication When Discussing Vaccines: A Systematic Review, Journal of Pediatric Nursing (2016), http://dx.doi.org/10.1016/j.pedn.2016.11.002
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in the U.S.). Different ethnicities as well as different countries/geographical areas have been noted to have different concerns regarding vaccination (Dube, Gagnon, Nickels, Jeram, & Schuster, 2014; Moran, Frank, Chatterjee, Murphy, & Baezconde-Garbanati, 2016). Hence, data extracted and placed into themes for this systematic review may not be fully generalizeable. Lastly, some studies included in this review were limited to examining the uptake of a specific vaccine. Again, this may limit the generalizeability of the identified themes as different vaccines may evoke different responses/concerns from parents. 6. Conclusion The findings from this systematic review overall lend credence to providers engaging with vaccine hesitant parents in a more participative format when discussing parental vaccination concerns in the context of a longitudinal, trusting, and supportive therapeutic relationship where personalized education is afforded to the parent. However, evidence quality in this review was generally considered low, and we are unable to definitively state if a collaborative/participatory interaction is the best approach vs. another type of provider-parent interaction such as the finding by Opel et al. (2013) that a presumptive type of interaction was more effective. Potentially efficacious communication practices when engaging in a conversation about vaccines with parents include: discussing the need for vaccination, discussing any specific diseases prevented/negative sequelae along with a strong recommendation for vaccination, showing respect and empathy towards parental concerns, possibly pursuing a vaccination recommendation in a parent that is initially resistant, utilizing a screening tool to identify concerns, and tailoring information to specific parent concerns. Acknowledgements The authors would like to extend their thanks to Dr. Julie Waldrop for her efforts in helping the researchers and to Mrs. Rebecca Connors for proof-reading the article and using her excellent editing abilities. References Alexander, A. B., Stupiansky, N. W., Ott, M. A., Herbenick, D., Reece, M., & Zimet, G. D. (2014). What parents and their adolescent sons suggest for male HPV vaccine messaging. Health Psychology, 33(5), 448–456. American Academy of Pediatrics (2012). Red book: 2012 report of the committee on Infectious diseases. (Practice recommendation no. 29th edition). Elk Grove Village, IL: American Academy of Pediatrics. Benin, A. L., Wisler-Scher, D. J., Colson, E., Shapiro, E. D., & Holmboe, E. S. (2006). Qualitative analysis of mothers' decision-making about vaccines for infants: The importance of trust. Pediatrics, 117(5), 1532–1541. Busse, J. W., Walji, R., & Kumanan, W. (2011). Parents' experiences discussing pediatric vaccination with healthcare providers: A survey of Canadian naturopathic patients. PloS One, 6(8), e22737. Buttenheim, A., Cherng, S., & Asch, D. (2013). Provider dismissal policies and clustering of vaccine-hesitant families: An agent-based modeling approach. Human Vaccines and Immunotherapeutics, 9(8), 1819–1824. http://dx.doi.org/10.4161/hv.25635. Centers for Disease Control and Prevention (2012). Talking with parents about vaccines for infants: Strategies for health care professionals. (Retrieved from) http://www. cdc.gov.libproxy.lib.unc.edu/vaccines/hcp/patient-ed/conversations/downloads/talkinfants-bw-office.pdf Covidence (2015). Systematic review software. Melbourne, Australia: Veritas Health Innovation (Available from www.covidence.org). Dempsey, A. F., Schaffer, S., Singer, D., Butchart, A., Davis, M., & Freed, G. L. (2011). Alternative vaccination schedule preferences among parents of young children. Pediatrics, 128(5), 848–856. http://dx.doi.org/10.1542/peds.2011-0400. Dube, E., Laberge, C., Guay, M., Bramadat, P., Roy, R., & Bettinger, J. (2013). Vaccine hesitancy: An overview. Human Vaccine and Immunotherapeutics, 9(8), 1763–1773. http://dx.doi.org/10.4161/hv.24657.
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Factors impacting influenza vaccination of urban low-income Latino children under nine years requiring two doses in the 2010–2011 season. Journal of Community Health, 40(2), 227–234. http://dx.doi. org/10.1007/s10900.014-9921.x. Hsieh, H., & Shannon, S. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277–1288. http://dx.doi.org/10.1177/104932 305275587. Kaufman, J., Synnot, A., Ryan, R., Hill, S., Horey, D., Willis, N., ... Robinson, P. (2013). Face to face interventions for informing or educating parents about early childhood vaccination. The Cochrane Database of Systematic Reviews, 31(5). http://dx.doi.org/10.1002/ 14651858.CD010038.pub2. Kempe, A., O'Leary, S. T., Kennedy, A., Crane, L. A., Allison, M. A., Beaty, B. L., ... Stokley, S. (2015). Physician response to parental requests to spread out the recommended vaccine schedule. Pediatrics, 135(4), 666–677. http://dx.doi.org/10.1542/peds.2014-3474. Leib, S., Liberatos, P., & Edwards, K. (2011). Pediatricians' experience and response to parental vaccine safety concerns and vaccine refusals: A survey of Connecticut pediatricians. Public Health Reports, 126(2), 13–23. McRee, A., Gilkey, M. B., & Dempsey, A. (2014). HPV vaccine hesitancy: Findings from a statewide survey of health care providers. Journal of Pediatric Healthcare, 28(6), 541–549. Mechanic, D. (1998). The functions and limitations of trust in the provision of medical care. Journal of Health Politics, Policy, and Law, 23(4), 661–686. Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia: Lippincott, Williams & Wilkins. Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & The PRISMA Group (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Medicine, 6(6), e1000097. http://dx.doi.org/10.1371/journal.pmed1000097. Mollema, L., Staal, J. M., Van-Steenbergen, J. E., Paulussen, T. G., & De-Melker, H. E. (2012). An exploratory qualitative assessment of factors influencing childhood vaccine providers' intention to recommend immunization in the Netherlands. BMC Public Health, 12(128) (Retrieved from) http://www.biomedcentral.com/1471-2458/12/128 Moran, M., Frank, L., Chatterjee, J., Murphy, S., & Baezconde-Garbanati, L. (2016). Information scanning and vaccine safety concerns amkong African American, Mexican American, and non-Hispanic white women. Patient Education and Counseling, 99(1), 147–153. http://dx.doi.org/10.1016/j.pec.2015.08.016. Nadeau, J., Bednarczyk, R., Masawi, M., Meldrum, M., Santilli, L., Zansky, S., ... McNutt, L. (2015). Vaccinating my way—Use of alternative vaccination schedules in New York state. The Journal of Pediatrics, 166(1), 151–156. http://dx.doi.org/10.1016/j.jpeds. 2014.09.013. Opel, D. J., Heritage, J., Taylor, J. A., Mangione-Smith, R. S., Salas, H. S., Devere, V., ... Robinson, J. D. (2013). The architecture of provider-parent discussions at health supervision visits. Pediatrics, 132(6), 1037–1046. Schwartz, J. L. (2013). “Model” patients and the consequences of provider responses to vaccine hesitancy. Human Vaccines & Immunotherapeutics, 9(12), 2663–2665. http://dx.doi.org/10.4161/hv.26371. Smith, P. J., Kennedy, A. M., Wooten, K., Gust, D. A., & Pickering, L. K. (2006). Association between health care providers' influence on parents who have concerns about vaccine safety and vaccination coverage. Pediatrics, 118(5), e1287–e1292. http://dx.doi. org/10.1542/peds.2006-0923. Tenrreiro, K. N. (2005). Time-efficient strategies to ensure vaccine risk/benefit communication. Journal of Pediatric Nursing, 20(6), 469–476 (doi:S0882-5963(05)00238-1). Thom, D. H., Hall, M. A., & Pawlson, L. G. (2004). Measuring patients' trust in physicians when assessing quality of care. Health Affairs, 23(4), 124–132.
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Journal of Pediatric Nursing
Provider-parent Communication When Discussing Vaccines: A Systematic Review1 John T. Connors, MSN, FNP-C ⁎, Kate L. Slotwinski, MSN, PMHNP-BC, Eric A. Hodges, PhD, FNP-BC University of North Carolina, School of Nursing, Carrington Hall, CB #7460, Chapel Hill, NC 27599-7460, United States
a r t i c l e
i n f o
Article history: Received 12 September 2016 Revised 17 October 2016 Accepted 7 November 2016 Available online xxxx Keywords: Provider interaction Vaccination Vaccine hesitant Communication
a b s t r a c t Problem: Expert literature on communication practices with vaccine hesitant parents posits that a nonconfrontational/participatory discussion with the parent would be the best approach to improve compliance. A prior literature review found limited evidence to recommend any particular face to face intervention other than to incorporate communication about vaccination effectiveness during an encounter. Hence, a systematic review was performed in an attempt to determine the most efficacious communication practices to use with parents with vaccination concerns. Eligibility Criteria: Quantitative and qualitative studies written in English that assessed the communication framework/style of the provider-parent interaction and studies where provider communication was listed as an intervention were reviewed. Sample: Nine articles were included in the sample. Results: The majority of the studies were descriptive and qualitative in nature with only one randomized controlled trial. Five of the 9 studies utilized a descriptive cross-sectional design. Two main themes included message types recommended or given by the provider and message types that were requested by the parent. Conclusions: Overall, findings showed that there is currently not enough information to definitively state the type of provider-parent communication style that should be employed to affect the parents' vaccination viewpoint. However, recurring themes of trust in the provider and a personalized provider-parent interaction were evident, which promotes a participatory type of interaction. Implications: The literature indirectly supports providers engaging with vaccine hesitant parents in a more individualized, participatory format, though higher quality and more rigorous studies that focus specifically on provider-parent communication practices are needed. Published by Elsevier Inc.
1. Background Parental concerns about childhood vaccinations have been shown to lead to vaccination hesitancy (VH), which places children at risk of not receiving the recommended vaccines by either being on an alternative vaccination schedule or forgoing specific vaccinations altogether. In a review by Dube et al. (2013), parental VH was defined as a parental attitude towards vaccination that is associated with overall increased under-vaccination of children and influenced broadly by “emotional, cultural, social, spiritual, political… [and] cognitive factors” (p. 1764). At an individual level, an identified vaccine hesitant parent runs the continuum from full vaccine compliance to near complete vaccine refusal and may request to employ an alternative vaccination schedule. Studies show that between 10% to 25% of parents utilize an alternative vaccination schedule (Dempsey et al., 2011; Nadeau et al., 2015). The 1 This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. ⁎ Corresponding author. E-mail addresses: [email protected], [email protected] (J.T. Connors).
significant number of parents choosing to utilize an alternative vaccination schedule or forego certain vaccinations is increasing (Freed, Clark, Butchart, Singer, & Davis, 2011; Glanz et al., 2013), which indicates that VH is a growing problem that places unvaccinated children at increased risk for contracting vaccine preventable diseases (VPD). This is especially problematic as provider tolerance of vaccine hesitant parents is decreasing, and parents that are not amenable to having their children vaccinated as currently recommended may gravitate towards more tolerant medical practices; thereby potentially exacerbating the magnitude of VPD outbreaks (Buttenheim, Cherng, & Asch, 2013). It is widely recognized that the interaction between providers and parents when discussing parental vaccination concerns is important in helping to alleviate parental concerns. Gust, Darling, Kennedy, and Schwartz (2008) investigated the main cause as to why vaccine hesitant parents reversed their decision about delaying or refusing a vaccine for their child and found the biggest contributing cause was the health care provider offering information about vaccines. However, providers seem to be increasingly non-tolerant of vaccine hesitant parents and less willing to discuss parental vaccination concerns (Leib, Liberatos, & Edwards, 2011).
http://dx.doi.org/10.1016/j.pedn.2016.11.002 0882-5963/Published by Elsevier Inc.
Please cite this article as: Connors, J.T., et al., Provider-parent Communication When Discussing Vaccines: A Systematic Review, Journal of Pediatric Nursing (2016), http://dx.doi.org/10.1016/j.pedn.2016.11.002
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Expert literature pertaining to communication practices with vaccine hesitant parents supports the importance of the health care provider-parent interaction. This literature posits that a nonconfrontational discussion and having honest communication with the parent would be the best approach (Healy, 2014; Schwartz, 2013; Tenrreiro, 2005). A systematic review by Kaufman et al. (2013) found limited evidence validating that face-to-face interventions (defined as individual counseling to multi-session interventions) led to increased vaccination rates in unimmunized children. Also, Kaufman et al. reported there was insufficient evidence to recommend any particular type of face to face intervention other than to incorporate communication about vaccination effectiveness during a clinical encounter. However, this systematic review was limited to evaluating only randomized controlled trials (RCT) up to 2012 and did not elucidate any specific communication practices that might increase vaccine uptake. Currently the American Academy of Pediatrics (2012) and the Centers for Disease Control and Prevention (2012) recommend a more collaborative/participatory discussion (listening attentively, welcoming questions, respecting parental authority) when dealing with parental vaccination concerns. However, no systematic reviews of the most efficacious communication practices (practices that may decrease parental vaccine hesitancy and increase the likelihood that vaccination will occur) were found; nor did the most recent review by Kaufman et al. (2013) identify any beneficial discussion frameworks when dealing with parental vaccination concerns. Therefore, a systematic review was performed to answer the following questions: Among parents with vaccination concerns, does a collaborative/participatory discussion between the provider and parent affect the parent's viewpoint on vaccination compared to other interaction types? Also, what are the most efficacious communication practices to use with parents when discussing vaccines? 2. Methods The literature search for this systematic review was performed using the National Library of Medicine (PubMed) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Major search terms were used to create search algorithms. The search algorithm used for both PubMed and CINAHL was as follows: (Provider OR Physician OR Nurse Practitioner OR Physician Assistant OR Pediatrician) AND (Parents OR Parent OR Guardian OR Mother OR Father) AND (Clinic Visit OR Communication OR Relationship OR Interaction OR Discussion OR Participatory OR Presumptive) AND (Vaccine Hesitancy OR Vaccination Hesitancy OR Non Vaccinating OR Vaccine Resistant OR Not Vaccinated). Articles were limited to studies involving humans and published from March 2011 to March 2016 in English. The limitation to articles published in the past five years was to ensure up-to-date information was included in the study and to exclude overlap from a prior systematic review that examined provider-parent face to face interactions. These searches resulted in 41 articles from the PubMed and CINAHL databases, which were transcribed from the RefWorks online citation management database into Covidence (2015) systematic review software for further review and analysis (Fig. 1). Exclusion criteria for full text review included: manuscripts not containing any primary data (expert opinion/individual article reviews), provider-parent communication was not assessed, and studies that were performed in developing countries where access to vaccines is a greater issue than parental concerns about vaccines (as there is a lack of vaccine availability and limited healthcare infrastructure). Inclusion criteria for full text review included: the communication framework/ style of the provider-parent interaction was investigated and/or communication practices were identified that may decrease parental vaccine hesitancy and increase the likelihood that vaccination will occur. Two reviewers independently reviewed the titles and abstracts of all publications produced by the initial search utilizing Covidence (2015) systematic review software. Any conflicts between reviewers were
resolved through discussion and consensus. A total of three conflicts were resolved by these means. Full-text review was performed by one reviewer with confirmation of the appropriateness to include into the sample by a second reviewer. Data extraction and a quality analysis were performed by one reviewer. Data extracted included communication practices, discussion and interaction type (participatory vs. other), the number of subjects included, study design, and the outcomes/findings (where appropriate) that pertained to communication practices and/or the interaction type. The quality of the evidence was analyzed by using the Cochrane criteria for assessing risk of bias (Higgins & Green, 2011) as well as the Melnyk and Fineout-Overholt (2011) tool for assessing the level of evidence. Conventional content analysis as described by Hsieh and Shannon (2005) was then used to organize, analyze, and interpret data from extracted information that fit under the broad a-priori headings of communication practices and discussion and interaction type(s). Numerous subcategories were identified under the broad a-priori headings and were able to be consolidated into a smaller number of categories. The use of conventional content analysis was seen as appropriate due to the limited amount of literature on the subject being investigated. 3. Results Forty total abstracts were reviewed with 15 excluded due to not meeting criteria. A total of 25 articles was subjected to a full text review with 16 being rejected for reasons (see Fig. 1) that included but were not limited to: the provider-parent communication was not assessed, the article was solely based on expert opinion, and the article was a review of another article. Nine articles met criteria to be included in the review. Extracted data was wide ranging due to the overabundance of qualitative studies in this synthesis. The level of the evidence overall was very low (see Table 1) based on the Melnyk Pyramid for evaluating the level of evidence (Melnyk & Fineout-Overholt, 2011). The overwhelming majority of the studies were descriptive and qualitative in nature with only one randomized controlled trial. Five of the 9 studies utilized a descriptive cross-sectional design. Additional study designs utilized were qualitative and employed observational methods and focus groups. Sample sizes ranged from n = 21 to n = 575, with 4 studies having sizes under 100. Studies were primarily limited to distinct homogenous populations (i.e. Hispanic, Caucasian, and African American) in outpatient clinics in discrete geographical locations (Canada, Denmark, the Netherlands, and suburban and inner city clinics in the U.S.). Taking the above information into account and applying the Cochrane criteria for assessing for risk of bias (Higgins & Green, 2011), the risk of bias and a possible lack of generalizability was noted to be high (see Table 1 for specific findings). Only 2 of 9 articles directly examined specific types of providerparent interactions during conversations about vaccines or utilized a specific provider-parent communication framework and measured the subsequent effect on the parental view of vaccination (Henrikson et al., 2015; Opel et al., 2013). One study that directly examined the type of provider-parent interaction with a provider-parent discussion framework, consisted of a presumptive (“we have to do some shots”) vs. a participatory (invite parental questions, use open ended questions) interaction (Opel et al., 2013). Another study utilized a more participatory framework during the provider-parent interaction (Henrikson et al., 2015). The results from the study performed by Henrikson et al. showed that a more participatory type of conversation framework did not have any effect on parental VH. However, the authors note that providers enrolled in the interventional arm of the study may not have been properly trained, and providers may not have been blinded to which arm of the study they were enrolled. The study performed by Opel et al. examined the use of a participatory vs. a presumptive discussion format when recommending vaccination in a study consisting of 111 participants. The study found that a larger proportion of parents initially resisted vaccine recommendations
Please cite this article as: Connors, J.T., et al., Provider-parent Communication When Discussing Vaccines: A Systematic Review, Journal of Pediatric Nursing (2016), http://dx.doi.org/10.1016/j.pedn.2016.11.002
Identification
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Records identified through database searching PubMed (n=35)
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Additional records identified through CINAHL (n=6)
Included
Eligibility
Screening
Records after duplicates removed (n=38)
Records screened (n=38)
Records excluded (n=15)
Full-text articles assessed for eligibility (n=23)
Full-text articles excluded, with reasons (n=14)
Studies included in synthesis (n=9)
- 7 Wrong study design (expert opinion papers or non-scholarly). - 1 Wrong intervention - 1 Wrong outcomes - 3 Type of providerparent communication not assessed - 2 Secondary source of information/primary source article included in current sample
Fig. 1. Prisma flow diagram. Note: Adapted from Moher D., Liberati A., Tetzlaff J., Altman D. G., The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and MetaAnalyses: The PRISMA Statement. PLoS Medicine 6(6): e1000097. doi:10.1371/journal.pmed1000097.
when providers used a participatory rather than a presumptive format. However, it was noted that the majority of the providers involved in the research did not elicit parental concerns prior to the provider-parent encounter, nor was it clear that a therapeutic relationship existed between the provider and the parent. Based upon the results of the only two studies found that investigated specific types of provider-parent interaction frameworks, this review took a more general approach to glean efficacious components of the provider-parent interaction when discussing vaccines. Data extracted in this review can be categorized as either the communication practices associated with the provider or the type of message requested by the parent.
Mollema et al., 2012). Provider flexibility with parental decisions on when vaccines will be given [flexibility was identified as a factor to help parents choose to vaccinate] (Mollema et al., 2012) as well as involving the parent in the vaccination process [allowing parents to hold their child while a vaccine is being administered] were seen as essential (Kempe et al., 2015). A single study found that pursuing a vaccination recommendation in a parent that is initially resistant is beneficial (Opel et al., 2013). Additionally, the study by Opel et al. (2013) found that provider-parent interactions about vaccines are able to be placed in either a presumptive or participatory format with the participatory format being associated with greater odds of initial parental resistance to vaccination.
3.1. Communication Practices Pertaining to the Provider 3.2. Message Type Requested by the Parent Provider themes included: tailoring information to specific parent concerns (McRee, Gilkey, & Dempsey, 2014), utilizing a screening tool to identify specific concerns [a majority of providers felt that a screening tool would be helpful] (McRee et al., 2014), and showing respect and empathy towards parental concerns [the doctor works with parents to ensure vaccination occurs and gives praise afterwards; affording respect and empathy towards vaccine hesitant and vaccine resistant parents] (Elverdam, 2011; Mollema, Staal, Van-Steenbergen, Paulussen, & De-Melker, 2012). Additionally, developing trust prior to discussing vaccination concerns [allopathic physicians seen as trusted sources of information; developing a trusting relationship first prior to discussing vaccination] was seen as important (Busse, Walji, & Kumanan, 2011;
Some general themes extracted from the parents' perspective included: the provider should discuss any specific diseases prevented/ negative sequelae and give a strong recommendation for vaccination [discussion limited to HPV vaccination] (Alexander et al., 2014), a primary concern for parents was safety (Busse et al., 2011), and discussing the need for vaccination was seen as being predictive of receipt of the vaccination (Hofstetter, Barrett, & Stockwell, 2015). Additionally, parents stated that their choice to vaccinate (or not vaccinate) affected the provider-parent relationship and introduced conflict if the provider was not willing to discuss parents' vaccination concerns (Busse et al., 2011).
Please cite this article as: Connors, J.T., et al., Provider-parent Communication When Discussing Vaccines: A Systematic Review, Journal of Pediatric Nursing (2016), http://dx.doi.org/10.1016/j.pedn.2016.11.002
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Table 1 Article review table. Citation
Sample
Study design and level of evidencea
Results
Study limitations
1. Alexander et al., 2014, USA
n = 21
Qualitative research design with semi-structured interviews (VI)
1. Clinical message given by the provider should include specific diseases prevented by the HPV vaccine, a discussion of the sexual nature of HPV, and a strong recommendation for adolescent males to receive the vaccine. 2. Commercial message given should be fear based. 1. Parents needing unbiased resources regarding vaccinations. 2. Physicians were seen to be biased sources of information by providing only pro-vaccine or incomplete information regarding parental concerns. 3. Many respondents most commonly endorsed both their allopathic and naturopathic physicians as trusted information resources; though only 15.8% of parents identified an allopathic physician as the most trusted source of information. 4. Parents were concerned with vaccine safety. 5. Parents (17.3%) noted that discussing vaccine choices (to vaccinate or not vaccinate) introduced conflict into the relationship. 1. The provider minimalizes the pain from the injection “... small pinprick”. 2. The doctor notes that he/she reluctantly does them. Doctors raising their voices when discussing vaccine side effects. 3. The provider and the parent conspire/work together to ensure the vaccination occurs. 4. The end of the vaccination is emphasized and praising of the child occurs. 5. The doctor talks about the harm he/she has done to the child due to the pain caused by the injection. 1. Fewer physicians in the intervention (Ask, Acknowledge, Advise) group reported high confidence in talking about risks (58% vs. 70%, p = 0.06), providing information (69% vs. 81%, p = 0.03), and answering difficult parent questions (54% vs. 69%, p = 0.01). 2. After adjusting for baseline self-efficacy, the intervention had no effect on physician self-efficacy or on parental vaccine hesitancy. 1. Caregivers who reported discussing receipt of the influenza vaccination with a provider were more likely to know their child needed two doses (55% vs.35%, p b 0.05) and have a fully vaccinated child (11% vs. 0%, p b 0.05).
1. Small sample size, study design, and primarily Hispanic and African American sample limits generalizeability. 2. Sample consisted of primarily non-vaccine hesitant parents.
2. Busse et al., n = 95 2011, Canada
Descriptive, cross-sectional (VI)
6. Elverdam, 2011, Denmark
Qualitative, observational (VI)
n = 25
7. Henrikson n = 347 et al., 2015, USA
Randomized controlled Trial (II)
8. Hofstetter n = 128 et al., 2015, USA
Descriptive cross-sectional design (VI)
9. Kempe et al., n = 534 2015, USA
Descriptive, cross-sectional (VI)
10. McRee et al., 2014, USA
n = 575 Descriptive, cross-sectional survey (VI)
11. Mollema et al., 2012, Netherlands
n = 25
Descriptive, qualitative study utilizing focus groups (VI)
1. Small sample size and study design limits generalizeability. 2. The questionnaire used only has face validity.
1. Small sample size and study design limits generalizeability. 2. Procedures are not explicitly stated and are discussed in generalities. 3. Performed on relatively non-vaccine hesitant population in Denmark.
1. Clinics may have been aware of being in the control vs. intervention arm after baseline data was gathered. 2. Providers may not have been completely trained at intervention site. 3. Power calculation performed with recommendation of a sample size of 500.
1. A convenience sample was used. However, bias may have been introduced as participants were drawn from another study that had an interventional (education on influenza) and control arm. 2. The survey/questionnaire was designed based upon expert opinion and prior studies. 3. The sample consists of primarily Hispanic families and may limit generalizability. 1. Telling parents that you think it is more painful for 1. No power analysis and no discussion of adequate their child to come back for multiple visits for shots sample size. rather than get them all at once. 44% FP and 53% 2. Procedures to transcribe, analyze data were not Peds (p = 0.15) stated that they do this and 10% FP explicitly stated. and 8% Peds (p b 0.0001) state that very effective. 3. Results are provider opinions on interventions to 2. Involving the parent in vaccine administration increase parental compliance with vaccination. (having the parent hold the child). 55%FP and 45% Peds (p = 0.003) stated that they do this and 17%FP and 11% Peds (p b 0.005) state that very effective. Provider strategies that were reported to be helpful 1. The total number of respondents to the questionnaire was 615 and only 575 were used. No explanation was given as to why some participant 1. Tailoring information to specific parent concerns responses were not included. (74%) or to parents' background (68%). 2. There is no discussion/justification of the sample 2. Providing information about HPV vaccine to parents size. No power analysis was performed. The particprior to the clinical visit (72%). ipation rate was noted to be small (16%). 3. Over half of providers felt that it would be helpful to have a screening tool to identify specific parental concerns (58%). 1. The sampling method might have selected a 1. Providers showing respect and empathy towards predominance of childhood vaccine providers with vaccine hesitant (VH)/vaccine resistant (VR) a positive attitude towards vaccines. parent(s) were identified themes. 2. Providers developing a trusting relationship with the VH/VR parent(s) first prior to discussing vaccination was another identified theme.
Please cite this article as: Connors, J.T., et al., Provider-parent Communication When Discussing Vaccines: A Systematic Review, Journal of Pediatric Nursing (2016), http://dx.doi.org/10.1016/j.pedn.2016.11.002
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Table 1 (continued) Citation
12. Opel et al., 2013, USA
a
Sample
Study design and level of evidencea
n = 111 Cross-sectional, observational (VI)
Results
Study limitations
3. An anthroposophical view was that the providers' task is to inform patients well; thereby allowing a parent to make a decision with that information. 4. Flexibility was identified as another factor to help parents to make a decision/choose how immunizations are given. 1. A larger proportion of parents resisted vaccine 1. The Hawthorne effect is a consideration as the recommendations when providers used a providers and parents were being videotaped. participatory rather than presumptive initiation format 2. Vaccine hesitant parents intentionally oversampled (83% vs. 26%; p b 0.001). This finding remained true leading to a higher risk of bias. among VH parents (89% vs. 30%; p b 0.001). 3. The rationale and potential side effects of vaccines 2. Pursuing a vaccination recommendation in a parent were not given to parents more often during first that is initially resistant may be beneficial. time vaccination conversations.
II = One or more RCTs; VI = single descriptive or qualitative study. (Melnyk & Fineout-Overholt, 2011).
4. Discussion In general the studies included in the sample were not directly comparable to one another as they were primarily qualitative in nature with varying study designs. This was unexpected, though not surprising, as researchers are currently exploring interaction types and communication processes that affect the vaccine hesitant parent's viewpoint on vaccination. Studies included in this review in some instances were limited to examining the uptake of a specific vaccine. As such, our ability to synthesize study outcomes and utilize a framework to grade the quality of the evidence was limited. However, some general discussion guidelines and findings from the provider or parent perspective can be elucidated with the understanding that the overall quality of the evidence is very low, which was determined by using the Cochrane criteria for assessing risk of bias (Higgins & Green, 2011) as well as the Melnyk and Fineout-Overholt (2011) tool for assessing the level of evidence. This systematic review of the literature showed that there is not currently enough information to definitively state the type of providerparent interaction that should be employed. However, extracted data placed under the headings of communication practices pertaining to the provider and the message type requested by the parent were able to be further categorized and synthesized. The findings of this review that having trust in the provider is important with regards to vaccination (Busse et al., 2011; Mollema et al., 2012) is further supported by a qualitative study performed by Benin, Wisler-Scher, Colson, Shapiro, and Holmboe (2006) who found that trust in the provider was found to be pivotal for a mothers' decision to vaccinate their child. Other studies show that parental trust in the provider is essential to ensure vaccination compliance (Gust et al., 2008; Smith, Kennedy, Wooten, Gust, & Pickering, 2006). The additional findings in this review also support the building of parental trust in the provider (as put forth by Benin et al., 2006) when taking into account the individual components of building trust. Specifically, Benin et al. found that a mothers' trust is gained when a provider spends time discussing vaccines, is knowledgeable about parents' vaccination concerns, offers satisfactory answers to parent questions, uses a patient centered approach, and does not deride parents' concerns. The identified themes of having a personalized provider-parent interaction (Alexander et al., 2014; Busse et al., 2011; Elverdam, 2011; McRee et al., 2014) and discussing the need for scheduled vaccinations (Hofstetter et al., 2015; Kempe et al., 2015; Opel et al., 2013) can be viewed as a means to helping build trust. Benin et al. also noted that the competence of the provider in dealing with parental vaccination concerns is linked to building parental trust in the provider. According to Mechanic (1998) and Thom, Hall, and Pawlson (2004) the competence of the provider consists of connecting both technical and interpersonal competence where the provider has the required knowledge and judgment to inform and treat a patient as well as the ability to communicate effectively. Extracted data from this review
supports providers having technical competence under the themes: discussing the need for scheduled vaccinations with the parent (Hofstetter et al., 2015; Kempe et al., 2015; Opel et al., 2013), and utilizing a screening tool to identify specific concerns (McRee et al., 2014). Competence in communication is implicit in many of the themes identified from this review and include: tailoring information to specific parent concerns (McRee et al., 2014), giving a strong recommendation for vaccination (Alexander et al., 2014), showing respect and empathy towards parental concerns (Elverdam, 2011; Mollema et al., 2012), and pursuing a vaccination recommendation in a parent that is initially resistant (Opel et al., 2013). The specific finding by Opel et al. (2013) of a presumptive approach (“we have to do some shots”) instead of a participatory interaction (invite parental questions, use open ended questions) being associated with decreased parental resistance to the provider recommendation to vaccinate does not support the current communication recommendations as put forth by the Centers for Disease Control and Prevention (2012) and Prevention and the American Academy of Pediatrics (2012). Though Opel et al. acknowledged that a participatory interaction helps develop trust with establishing a therapeutic relationship over time, it may well be beneficial to initiate the vaccination recommendation in more of a presumptive format when examining a provider-parent initial interaction regarding vaccine recommendations if other factors are not taken into consideration. Also, when taking into account the potential longitudinal effects of patient trust and perceived competence of the provider, it may be helpful to identify any vaccination concerns prior to the encounter to determine if a more participatory discussion format would be warranted vs. a presumptive or other type of format or conversation framework. Hence, deeper understanding and further research is needed on the effects of the style of the provider parent interaction, preferably taking into account measurements of trust, competence in the provider, and eliciting any parental vaccination concerns prior to offering a vaccination recommendation. 5. Limitations Limitations of this systematic review include a paucity of high quality data that is directly comparable. Thus, broad categories had to be developed for data extraction and the development of themes. This likely provides an incomplete picture of the provider parent interaction and communication processes and only affords what would be considered low quality evidence for incorporation into clinical practices. Future, higher quality and more rigorous studies that focus specifically on provider-parent communication practices should be performed, as currently identified studies are primarily qualitative and descriptive in nature. Also, many of the studies included in this review were limited to distinct homogenous populations (i.e. Hispanic, Caucasian, and African American) in outpatient clinics in discrete geographical locations (Canada, Denmark, the Netherlands, and suburban and inner city clinics
Please cite this article as: Connors, J.T., et al., Provider-parent Communication When Discussing Vaccines: A Systematic Review, Journal of Pediatric Nursing (2016), http://dx.doi.org/10.1016/j.pedn.2016.11.002
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in the U.S.). Different ethnicities as well as different countries/geographical areas have been noted to have different concerns regarding vaccination (Dube, Gagnon, Nickels, Jeram, & Schuster, 2014; Moran, Frank, Chatterjee, Murphy, & Baezconde-Garbanati, 2016). Hence, data extracted and placed into themes for this systematic review may not be fully generalizeable. Lastly, some studies included in this review were limited to examining the uptake of a specific vaccine. Again, this may limit the generalizeability of the identified themes as different vaccines may evoke different responses/concerns from parents. 6. Conclusion The findings from this systematic review overall lend credence to providers engaging with vaccine hesitant parents in a more participative format when discussing parental vaccination concerns in the context of a longitudinal, trusting, and supportive therapeutic relationship where personalized education is afforded to the parent. However, evidence quality in this review was generally considered low, and we are unable to definitively state if a collaborative/participatory interaction is the best approach vs. another type of provider-parent interaction such as the finding by Opel et al. (2013) that a presumptive type of interaction was more effective. Potentially efficacious communication practices when engaging in a conversation about vaccines with parents include: discussing the need for vaccination, discussing any specific diseases prevented/negative sequelae along with a strong recommendation for vaccination, showing respect and empathy towards parental concerns, possibly pursuing a vaccination recommendation in a parent that is initially resistant, utilizing a screening tool to identify concerns, and tailoring information to specific parent concerns. Acknowledgements The authors would like to extend their thanks to Dr. Julie Waldrop for her efforts in helping the researchers and to Mrs. Rebecca Connors for proof-reading the article and using her excellent editing abilities. References Alexander, A. B., Stupiansky, N. W., Ott, M. A., Herbenick, D., Reece, M., & Zimet, G. D. (2014). What parents and their adolescent sons suggest for male HPV vaccine messaging. Health Psychology, 33(5), 448–456. American Academy of Pediatrics (2012). Red book: 2012 report of the committee on Infectious diseases. (Practice recommendation no. 29th edition). Elk Grove Village, IL: American Academy of Pediatrics. Benin, A. L., Wisler-Scher, D. J., Colson, E., Shapiro, E. D., & Holmboe, E. S. (2006). Qualitative analysis of mothers' decision-making about vaccines for infants: The importance of trust. Pediatrics, 117(5), 1532–1541. Busse, J. W., Walji, R., & Kumanan, W. (2011). Parents' experiences discussing pediatric vaccination with healthcare providers: A survey of Canadian naturopathic patients. PloS One, 6(8), e22737. Buttenheim, A., Cherng, S., & Asch, D. (2013). Provider dismissal policies and clustering of vaccine-hesitant families: An agent-based modeling approach. Human Vaccines and Immunotherapeutics, 9(8), 1819–1824. http://dx.doi.org/10.4161/hv.25635. Centers for Disease Control and Prevention (2012). Talking with parents about vaccines for infants: Strategies for health care professionals. (Retrieved from) http://www. cdc.gov.libproxy.lib.unc.edu/vaccines/hcp/patient-ed/conversations/downloads/talkinfants-bw-office.pdf Covidence (2015). Systematic review software. Melbourne, Australia: Veritas Health Innovation (Available from www.covidence.org). Dempsey, A. F., Schaffer, S., Singer, D., Butchart, A., Davis, M., & Freed, G. L. (2011). Alternative vaccination schedule preferences among parents of young children. Pediatrics, 128(5), 848–856. http://dx.doi.org/10.1542/peds.2011-0400. Dube, E., Laberge, C., Guay, M., Bramadat, P., Roy, R., & Bettinger, J. (2013). Vaccine hesitancy: An overview. Human Vaccine and Immunotherapeutics, 9(8), 1763–1773. http://dx.doi.org/10.4161/hv.24657.
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Please cite this article as: Connors, J.T., et al., Provider-parent Communication When Discussing Vaccines: A Systematic Review, Journal of Pediatric Nursing (2016), http://dx.doi.org/10.1016/j.pedn.2016.11.002