Physician Communication Training and Parental Vaccine Hesitancy: A Randomized Trial

"A physician-targeted communications intervention was not effective in changing maternal vaccine hesitancy from birth to 6 months or in improving physician confidence in communicating with parents....Further research should determine the most effective approaches to addressing vaccine hesitancy."

Noting that physicians have a major influence on parental vaccine decisions yet may lack confidence in addressing parents' vaccine concerns, the researchers conducted a community-based, clinic-level, 2-arm cluster randomised trial in paediatric and family practice outpatient clinics in Washington State in the United States (US) from March 2012 to December 2013. They hypothesised that training physicians would improve their self-efficacy in communicating with parents about vaccines, which would subsequently improve physician-parent communication and positively influence parental attitudes and beliefs about vaccines.

The researchers enrolled and randomised 56 clinics, conducting trainings in the 30 clinics randomised to the intervention group. These clinics received training on a communication strategy developed by Vax Northwest, a partnership in Washington State. The strategy, "Ask, Acknowledge, Advise," was adapted from communication models found to be effective, informed by constructs from the theory of planned behaviour, and based on best practices in physician-patient communication adapted to vaccine conversations. According to this strategy, the "ask" step cues physicians to invite parental vaccine questions and concerns, the "acknowledge" step reinforces communication of respect and empathy for the parent's concerns and creation of a trusting environment, and the "advise" step prompts physicians to recommend immunisation, educate about the benefits and risks of vaccines and vaccine-preventable disease, and end the consultation with a mutually agreed on action such as vaccinating or an appointment to discuss further.

The main component of the training was a 45-minute training administered by a paediatrician immunisation expert and a health educator. The training included didactic presentation of data on vaccine hesitancy, the strong provider influence on parental vaccine decisions, and the importance of trust-building around vaccine decisions. Interactive components included facilitated discussion of videos modeling the method and how clinic flow could be adjusted to improve vaccine hesitancy. Training participants also received paper materials with consistent branding ("Let’s Talk Vaccines") detailing the framework. To reinforce training messages and reach nonattendees, each clinic received these materials plus branded leave-behind buttons, notepads, and parent-facing resources. The health educator visited each clinic 3 months after training and provided branded mugs and more supplies of training materials. In addition, each eligible physician, regardless of training attendance, received 6 months of monthly email newsletters, a link to the study website, which included a webinar version of the training, and technical assistance on request, such as responses to unusual parent questions about vaccine safety. The 26 control clinics did not receive any of these intervention components. After data collection concluded at each control clinic, the health educator delivered the training materials and offered study physicians access to online training materials via the study website.

The researchers enrolled 488 of the mothers of healthy newborns from the 56 clinics at the hospital of birth. Of these mothers, 391 completed the baseline survey and 347 completed the follow-up survey. At baseline, groups were similar on all variables except maternal race and ethnicity. Maternal vaccine hesitancy at month 6, the primary study outcome, was assessed by maternal score on the Parental Attitudes on Childhood Vaccines (PACV) survey. The PACV is a 15-item scale with high reliability and is associated with vaccine behaviour: as a dichotomous measure as "hesitant" or "nonhesitant" and as an ordinal measure with 5 levels. The secondary outcome was physician self-efficacy in communicating with parents by using 3 vaccine communication domains (confidence in talking about risks, providing information, and answering difficult parent questions).

Maternal vaccine hesitancy at baseline and follow-up changed from 9.8% to 7.5% in the intervention group and 12.6% to 8.0% in the control group. The intervention had no detectable effect on maternal vaccine hesitancy (adjusted odds ratio 1.22, 95% confidence interval 0.47–2.68). At follow-up, physician self-efficacy in communicating with parents was not significantly different between intervention and control groups.

The researchers surmise that the null effect may have been due to intervention reach. Only 67% of the intended physician population attended training, but all were given access to an online version of the training and resources and emailed repeatedly with information, technical support, and reinforcement of intervention messages. The researchers do not know how many intervention physicians used the online training or whether physicians attended only partial in-person training. Therefore, mothers could have encountered an "untrained" physician. However, the intervention was designed to translate meaningfully into practice and thus may reflect realistic implementation of interventions of this type. Another reason for the null finding may be insufficient intervention intensity. Despite 6 months of reinforcement of the training messages, the intervention in effect was a 1-dose, 45-minute training. Also, more recent data suggest that a strong physician recommendation may influence parents' vaccine choices in the short term. This intervention stressed the importance of physician recommendation, but focused more on long-term relationship building.

The researchers offer several recommendations for future research. "First, work in identifying and targeting interventions at hesitant parents may be warranted. The relative impact of vaccine hesitancy on vaccine coverage compared with other factors, including access and beliefs specific to cultural groups, deserves further study. Increasing intervention intensity through multiple levels of influence may yield better results; for example, communication training combined with clinic, systems, peer-to-peer, or policy-level interventions may have a greater collective impact on maternal confidence in vaccines. Also, more foundational and conceptual work is needed on the optimal approaches to communicating with vaccine-hesitant parents, and delivering feasible, high-dose communications interventions with physicians where the ultimate target is parent behavior."