Vaccination uptake by vaccine hesitant parents attending a Specialist Immunisation Clinic in Australia. Margie Danchin, Alissa McMinn, Nigel Crawford, Julie Leask, Thomas Forbes Paediatrician, Department of General Medicine, RCH Senior Research Fellow, Vaccine and Immunisation and Rotavirus Research Group, MCRI Senior Fellow, Department of Paediatrics, The University of Melbourne
Background Vaccine hesitancy (VH) is an issue of global concern WHO SAGE Working Group on Vaccine Hesitancy research in this area has doubled in the last five years It is clear that parental concerns are increasing VPDs less common Vaccine schedules becoming more complex More access to information through the internet and social media Concern about safety and necessity of vaccines
Background Complex issue, context specific present in both developed and developing country settings Evidence suggests that the quality of communication between healthcare providers and parents can influence parental immunisation acceptance Various communication approaches have been described in the literature Participatory vs presumptive communication styles
Vaccine communication Participatory communication: collaborative discussion style vs Presumptive communication: declaration of the necessity for vaccines up front with pursuit of vaccination in the face of parental resistance presumptive communication associated with improved intention to vaccinate but reduced parental satisfaction in primary care The Architecture of Provider Parent Vaccine Discussions at Health Supervision Visits, Opel Pediatrics 2013 not appropriate in a specialist immunisation clinic (SIC) as parents have already declared their vaccine concerns by referral to and attendance at the clinic
Vaccine communication SIC communication style at RCH - guiding style (similar to Motivational Interviewing) - first ask permission to discuss a parent s concerns and then utilise active listening techniques - clinician then guides the conversation using open questions - discuss both the vaccine and disease risks and benefits, supported by easily digestible written and online resources - positive recommendation to vaccinate We aimed to describe immunisation uptake following SIC consultation, using a guiding style, according to pre-clinic parental position on immunisation
Methods Single tertiary paediatric SIC, RCH, Melbourne Retrospective descriptive study classified VH families according to three proposed parental positions on immunisation at initial clinic attendance - parents vaccine concerns - vaccine uptake - vaccines omitted A participatory or guiding communication style was used by immunisation clinic physicians Immunisation status at follow up was ascertained via Australian Children s Immunisation Register (ACIR) and National HPV Program Register and compared between groups
Sub-classification of Vaccine Hesitancy: Definitions Parental Position Unquestioning acceptor Cautious acceptor Hesitant (Group 1) Late or selective vaccinator (Group 2) Refuser (Group 3) Definition Vaccinate no specificquestions Vaccinate despite minor concerns Vaccinate but have significant concerns. Focused on vaccine risk. Trust in healthcare provider key High levels of vaccine knowledge Significant concerns about vaccination result in this group choosing to delay or select only some recommended vaccines Highest level of vaccine knowledge Refuse all vaccines. Strong and specific religious, cultural or philosophical beliefs. Lower levels of vaccine knowledge Adapted from Leask et al, BMC Pediatrics 2012
Results Between June 2012 and January 2013 (7-month study period) - 171 new referrals 28% were for VH: 38/48 attended 49% AEFI 13% special risk - Of the 38 parents in the VH cohort: classification 13 (34%) hesitant 21 (55%) late/selective vaccinators 4 (11%) vaccine refusers - Mean follow up post-sic attendance was 14.5 months - Vaccine uptake: ACIR record available for 71%; phone-call 29%
Indications for Referral to the SIC
Demographics - 53% male - median age 11 months Referral source - GP: 74% - paed: 21% -ED: 5% Majority were only children (58%) and first born (68%) Prior VPD - Child 21% (3 varicella cases and 5 pertussis cases) - Family member 11% (antenatal measles (1 case), HBV (1 case) and pertussis (2 cases) )
Parents vaccine concerns Top 3 concerns - side effects of vaccines/vaccine safety (58%) - concerns about links with developmental disorders (40%) - overloading the child s immune system (24%) - child was too young to receive vaccines (16%) - vaccine ingredients (5%) - preference for complimentary therapies (5%) - vaccines were not effective (3%) - preference to rely on community herd immunity (3%).
Vaccination Outcome in VH Cohort at Follow Up by Presenting Hesitancy Status. VH families were separated into three groups according to Pre-clinic parental position on vaccination: Group 1 - hesitant Group 2 - late/selective Group 3 - refusing A significant correlation between presenting parental position and vaccination outcome at follow up was observed (p = 0.002)
Vaccination Outcome in VH Cohort at Follow Up by Presenting Hesitancy Status.
Omission of Individual Vaccines at Follow Up, According to Pre-Clinic Hesitancy Status Vaccine Omitted Group 1 Hesitant n = 13 (%) Group 2 Late/Selective n = 21 (%) Group 3 Refusing n = 4 (%) All Groups n = 38 Diphtheria, Tetanus, Pertussis 3 (23) 13 (62) 3 (75) 19 (50) H. influenza Type B 4 (31) 14 (67) 3 (75) 21 (55) Hepatitis B 5 (38) 16 (76) 4 (100) 25 (66) Polio 3 (23) 13 (62) 3 (75) 19 (50) Pneumococcal 4 (31) 12 (57) 3/3 (100)* 19/37 (51)* Rotavirus** 3/10 (30%) 6/8 (75) 0 9/18 (50) Meningococcal 3 (23) 13 (62) 4 (100) 20 (53) Varicella 0 10 (48) 2 (50) 12 (32) Measles, Mumps, Rubella 2 (15) 15 (71) 3 (75) 20 (53) Human Papillomavirus 0 0 1 (25) 1 (3)
Conclusion Referrals for VH families - majority from GP s - reflects barriers for GPs: time, less detailed knowledge, how to communicate risk Parents concerns - Vaccine safety, including serious adverse events, top concern for parents - possible association between MMR and autism still lingers Vaccine uptake - only 26% of the total VH cohort proceeded with full vaccine uptake according to NIP - 31% received no further vaccines
Conclusion For the overall VH cohort - When analysed by pre-clinic parental position on immunisation, there was a trend for hesitant families to proceed with full immunisation selective families to continue selective immunisation refusing families to remain unimmunised (p<0.0001) - majority chose selective immunisation (42%) following SIC consultation not tested for safety
Conclusion Tailored communication approaches based on parental position on immunisation may optimise clinic resources and engagement of families, but require prospective research evaluation - use of a guiding style - make a positive recommendation to vaccinate Future research compare vaccine uptake in VH familes who attend a SIC compared with primary care
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