New way to tackle vaccine hesitancy tested, found wanting

SEATTLE--Group Health Research Institute conducted the first randomized trial to test an intervention aimed at improving hesitancy about early childhood vaccines by working directly with doctors. Vax Northwest, a Washington state public-private partnership, developed the intervention. The results are reported in Pediatrics in "Physician Communication Training and Parental Vaccine Hesitancy: A Randomized Trial," with an accompanying editorial: "Physician Communication with Vaccine-Hesitant Parents: The Start, Not the End, of the Story."

Here's why the team did the research: Vaccines are children's best protection from infectious diseases, including ones that can cause death. But many parents hesitate to vaccinate their children, particularly in Washington state. And delaying or refusing vaccines can lead to outbreaks of vaccine-preventable diseases, as recently happened with measles at Disneyland. Doctors can influence decisions about childhood vaccines, but they may lack confidence in addressing concerns about vaccines.

The trial included 347 mothers of newborns receiving care at 56 primary care clinics in two western Washington counties. It tested a one-time, 45-minute training session and six months of follow-up communication for doctors in the intervention clinics--with comparison to control clinics with no training. The communication training encouraged providers to use respectful, open dialogue with parents while recommending vaccination, and it included anyone working in the clinic who wished to attend.

Trial results

Vaccine hesitancy rates declined slightly in both the 30 intervention and 26 control clinics over the six-month study period--and did not differ significantly between them. The intervention did not change either mothers' vaccine hesitancy, or doctors' confidence in communicating about vaccines.

The decrease in vaccine hesitancy may be related to a whooping cough (pertussis) outbreak that happened in Washington state during the study period, and new state legislation requiring a doctor's note for exemption from schools' vaccination requirements, according to lead author Nora Henrikson, PhD, a research associate at Group Health Research Institute. "If vaccine hesitancy is really decreasing, that's potentially good news." Dr. Henrikson added. "But we still don't understand how parents' hesitancy changes over time, and we still see outbreaks of vaccine-preventable disease."

The trial's novel intervention--called Ask, Acknowledge, and Advise--was developed and pretested by Vax Northwest, which includes Group Health, WithinReach, Seattle Children's, BestStart Washington, and the Washington State Department of Health. Vax Northwest is a public-private partnership working to ensure all children and communities in Washington state are protected from vaccine-preventable disease.

Ideally, the measured outcome would have been vaccinations. But because vaccine delay and refusal are so rare, testing an impact on this outcome would have required an extremely large and expensive study.

What's next?

"More research is needed to identify strategies that help primary-care doctors to address parents' vaccine hesitancy," said Dr. Henrikson's coauthor, principal investigator David C. Grossman, MD, MPH. He is a Group Health Research Institute senior investigator, Group Health pediatrician and medical director for population and purchaser strategy, and professor of health services at the University of Washington (UW) School of Public Health and adjunct professor of pediatrics at the UW School of Medicine.

The trial intervention was designed to be easily translated to practice, but perhaps a longer, higher-intensity version of the training might be more effective. Or, since most parents are already confident about vaccines, doctors might need a way to identify hesitant parents reliably so they can allow enough time during visits to discuss vaccines. "Doctors are the main source of vaccine information for most parents," Dr. Grossman said, "so they need evidence-based ways to address parental vaccine concerns." You can read a blog that he wrote about this work.

"Organizations across the country are looking for ways to communicate the value of vaccination to protect our families and communities," said another coauthor, Douglas J. Opel, MD, MPH. He is an investigator at the Treuman Katz Center for Pediatric Bioethics at Seattle Children's Hospital Research Institute, an assistant professor in the Divisions of Bioethics and General Pediatrics at the UW School of Medicine, and an affiliate investigator at Group Health Research Institute. "That's why we've done this research and will keep trying to tackle vaccine hesitancy."

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This research was funded by the Group Health Foundation and the Bill & Melinda Gates Foundation.

Drs. Henrikson, Grossman, and Opel's coauthors are John Dunn, MD, MPH, a Group Health pediatrician and an affiliate investigator at Group Health Research Institute; Jennifer Nelson, PhD, a senior investigator, Lou Grothaus, MS, formerly senior biostatistician, and Aaron Scrol, MA, a project manager, of Group Health Research Institute; Todd Faubion, PhD, immunization manager at WithinReach; Michele Roberts, MPH, MCHES, director of the Office of Immunization and Child Profile at the State of Washington Dept. of Health; and Edgar K. Marcuse, MD, MPH, emeritus professor of pediatrics at the UW School of Medicine and Seattle Children's Hospital.

VaxNorthwest

The Vax Northwest partnership works to ensure that all parents have access to reliable, accurate information about vaccines. The partnership was formed in 2008, recognizing the need for scientifically evaluated interventions addressing the challenge of vaccine hesitancy (at that time, Washington State had the highest rate of kindergarten exemptions in the country). Vaccine hesitancy is defined as reticence to immunize per the Centers for Disease Control and Prevention's recommended schedule or to immunize at all. The partnership is composed of leadership from five organizations: BestStart Washington, Group Health Cooperative, Seattle Children's Hospital, the Washington State Department of Health, and WithinReach. Working under the Collective Impact model, WithinReach staffs and supports the partnership, ensuring that it is guided by a clear mission and body of work.

WithinReach

WithinReach works to ensure all Washington families have the basic resources that they need to be healthy. Founded in 1988, the organization serves over 300,000 Washingtonians annually, through a combination of technology and in-person strategies, including toll-free hotlines, client-focused websites, and in-person assistance. WithinReach focuses on five core areas to promote healthy families and communities: health care access, food access, child development, immunizations, and breastfeeding. The organization also engages with policy and decision makers to create positive change for struggling families through the development of legislation that will enhance overall family health and economic stability. Follow WithinReach on Facebook and Twitter.

Seattle Children's

Seattle Children's Hospital, Foundation, and Research Institute together deliver superior patient care, advance new discoveries and treatments through pediatric research, and serve as the pediatric and adolescent academic medical referral center for Washington, Alaska, Montana, and Idaho-the largest region of any children's hospital in the country. Consistently ranked as one of the best children's hospitals in the country by U.S. News & World Report, Seattle Children's Hospital specializes in meeting the unique physical, emotional, and developmental needs of children from infancy through young adulthood. For more than 100 years, the hospital has been dedicated to providing top-quality care to every child in who needs it, regardless of the family's ability to pay. Seattle Children's Hospital and Research Foundation gathers community support and raises funds for Seattle Children's Hospital and Seattle Children's Research Institute. Located in downtown Seattle's biotech corridor, Seattle Children's Research Institute is pushing the boundaries of medical research to find cures for pediatric diseases and improve outcomes for children all over the world. Internationally recognized investigators and staff at the research institute are advancing new discoveries in cancer, genetics, immunology, pathology, infectious disease, injury prevention, and bioethics, among others. For more information, visit seattlechildrens.org or follow us on Twitter, Facebook and Instagram.

BestStart Washington

BestStart Washington is a 501c3 organization that gives children their best start toward lifelong success and resilience by working to improve their physical health, emotional wellbeing, and academic achievement. Founded and governed by pediatricians, BestStart Washington collaborates with community pediatricians, families and other partners to develop and fund innovative programs that give children the best possible start on healthy and productive lives.

Washington State Department of Health

The Washington State Department of Health's mission is to protect and improve the health of people in Washington state. Our programs and services help prevent illness and injury, promote healthy places to live and work, provide education to help people make good health decisions and ensure our state is prepared for emergencies. Helping prevent illness is a cornerstone of public health. We work to improve health through disease and injury prevention, immunization, and newborn screening for prenatal disease programs. The Washington State Department of Health works with many partners to provide educational and training programs as well as health and safety information to help people make healthy choices. By licensing healthcare professionals, investigating disease outbreaks, and preparing for emergencies, we help ensure a safer and healthier Washington.

Group Health Cooperative

Group Health is a unique health care system linking care delivery and insurance coverage in order to achieve one goal--affordable, quality health care for all. Our innovative approach has made us a national leader in a new era of health care reform, and our goals have remained the same since we began serving patients in 1947. As a nonprofit organization, Group Health helps nearly 600,000 patients throughout Washington state achieve better health. Our focus on preventive care, combined with medical education, a charitable foundation and a nationally recognized research institute, advances health in the community in a way no one else can. Group Health supports events, programs, and organizations that share this commitment to strengthening health in our communities. For more information about Group Health, visit http://www.ghc.org.

Group Health Foundation

The Group Health Foundation supports Group Health in providing the best care for our members and creating better health in our communities. Two areas of focus for the Foundation are children's immunizations-providing more than 33,000 free vaccines-and the support of research to improve patient care, reduce costs, and increase patient satisfaction at the clinical level.

Group Health Research Institute

Group Health Research Institute does practical research that helps people like you and your family stay healthy. The Institute is the research arm of Seattle-based Group Health Cooperative, a consumer-governed, nonprofit health care system. Founded in 1947, Group Health Cooperative coordinates health care and coverage. Group Health Research Institute changed its name from Group Health Center for Health Studies in 2009. The Institute has conducted nonproprietary public-interest research on preventing, diagnosing, and treating major health problems since 1983. Government and private research grants provide its main funding. Follow Group Health research on Facebook, Twitter, or YouTube.

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