Physician Response to Parental Requests to Spread Out the Recommended Vaccine Schedule

Discussion

In contrast to much of the previous literature regarding parents who refuse all or specific vaccines, the current study focused on the larger group of parents who intend to vaccinate but request to spread out the recommended vaccine schedule. Our data demonstrate that primary care physicians are spending a good deal of time discussing vaccines when parents have concerns, that they are trying a variety of methods of handling requests to spread out the vaccine schedule, and that, in general, they find few methods to be effective in increasing timely vaccination. Although they perceive that there are harms associated with spreading out vaccines, they usually agree to do so.

Data suggest that during the past decade, increasing numbers of parents are choosing to deviate from the recommended vaccine schedule, either using published alternative schedules^21–23 or, more frequently, requesting to spread out the recommended schedule without a specific model.^4,7 Delaying vaccines has led to more children who are undervaccinated. For example, the prevalence of undervaccination in the first 2 years of life within 8 managed care organizations increased from 41.8% in 2004 to 54.4% in 2008, with ∼13% of the total estimated to be undervaccinated by choice.² Other national surveys have yielded similar percentages of parents who reported requesting some type of alternative schedule.^7,12 Our data are difficult to directly compare with these parent surveys because they represent incidence rather than prevalence data and are from the physician’s perspective rather than self-report of parents.

Physicians reported that parents usually discussed their reasons for wanting to spread out vaccines. Reasons given were similar to other published reasons for either deferral or refusal, including concerns about short- and long-term complications, belief that their child is unlikely to get a vaccine-preventable disease, concerns about weakening their child’s immune system, and the belief that the diseases are not severe enough to warrant vaccination.^12–14,24 Some commonly reported reasons, however, were more specific to the request to vaccinate on a modified schedule, including a friend or relative’s positive experience with an alternative schedule and the belief that the parents should play a central role in medical decisions about their child. These responses support the importance of social networks in affecting vaccine decisions²⁵ and underline the importance of control over medical decision-making among vaccine hesitant parents.

Many physicians reported tension between the need to build trust with families by being willing to compromise on the schedule while simultaneously feeling they were putting children at risk and causing them unnecessary pain by spreading out vaccines on multiple visits. A sizable portion of physicians, especially pediatricians, reported that this issue was decreasing their job satisfaction. Roughly half of all physicians reported they spend ≥10 minutes in discussions with parents who have substantial vaccine concerns, and among pediatricians, this number was almost 60%. Previous work has shown that both pediatricians and parents²⁶ estimate that well-child visits average ∼18 minutes. Therefore, if physician estimates are accurate, they may be spending more than half of their appointment time with families who have vaccine concerns discussing this issue alone. Studies about the content of well-child visits show that although immunizations are virtually always discussed, as available visit time decreases, other issues such as developmental assessment, feeding issues, toilet training, child care, guidance about emotional support, sleep position, car seats, and parental smoking are short-changed.²⁷ A 2006 examination of previous policy statements by the AAP found 162 verbal health advice directives on which pediatricians were recommended to counsel parents and patients throughout childhood.²⁸ When seen in this context, the amount of visit time physicians are spending on vaccine concerns may be compromising their ability to deliver comprehensive preventive care to children of parents with substantial vaccine concerns.

Compared with a 2009 survey conducted in sentinel networks using the same methodology and the same question as in the current study,²⁹ the data reported here show a marked difference in physician responses to parental requests to spread out the vaccine schedule. In 2009, only 13% reported often or always agreeing to spread out vaccines, whereas 37% in the present survey often or always agreed to do so. This shift may reflect changes in the beliefs of physicians about what is effective in working with hesitant parents, adherence to published recommendations about how to build trust with vaccine-hesitant parents, or simply a pragmatic reaction to the amount of time it takes to discuss parents’ concerns in the context of a busy practice setting and, perhaps, the perceived futility of doing so. Our multivariable model suggests that the importance of building trust with parents is a motivator for agreeing to spread out vaccines, but a strongly held belief that agreeing to do so gives parents a mixed message makes physicians less inclined to agree to spread out vaccines.

Pockets of underimmunization have been associated with outbreaks of several vaccine-preventable diseases including pertussis, varicella, pneumococcal disease,^9,10,30,31 and, especially in recent years, measles.^8,31,32 Additional potential harms of spreading out the vaccine schedule have not been studied. The safety of alternative schedules is unknown, although a recent study demonstrated that delay of the measles, mumps, and rubella vaccine until after 15 months was associated with a higher rate of febrile seizures.³³ The psychological effect of bringing children back for single shots at frequent intervals, which most physicians surveyed thought was more painful than receiving immunizations simultaneously, has also not been assessed.

Although physicians report using many strategies in response to requests to deviate from the recommended schedule, they had a relatively bleak perception of the effectiveness of most of them. The strategy most often deemed effective was considered “very effective” by only 20% of physicians. In fact, as pointed out by a recent systematic review, there is virtually no published evidence at present demonstrating effective interventions to persuade parents to vaccinate when they already wish to delay or refuse.³⁴ Most publications have focused exclusively on the interaction between providers and parents and addressed physician communication style, motivational interviewing techniques, or tailoring messages to specific parental positions.^35–40 Focusing interventions on this key relationship has been guided by qualitative and survey data from parents in which they cite health care providers as their most trusted source of vaccine information.^13,41,42 Indeed, among parent survey respondents who have considered delaying or refusing vaccines, the recommendation of a health provider has been reported as the most common reason for getting vaccines as recommended.^12,43

However, it is not clear that providers are having success in changing the minds of parents who come in already requesting to either spread out or refuse vaccines. In a recent study, only 69% of parents who delayed vaccines and 38% of parents who refused vaccines expressed a high level of trust in their pediatrician’s advice on vaccines.⁴⁴ Despite the educational materials and tools available from national organizations focused⁴⁵ on how to communicate with hesitant parents and what type of messages to give, almost none have been actually studied in a comparative effectiveness trial to assess the impact of their use. The 1 recent randomized trial to compare different types of messages to increase measles, mumps, and rubella vaccine vaccination found that none increased parental intent to vaccinate and those that attempted to increase concerns about diseases or correct false information about vaccines actually decreased intent to vaccinate among parents who had the least favorable vaccine attitudes.⁴⁶ Although the messages were delivered over the Internet rather than in a clinical setting by a trusted provider, these results nonetheless underline the importance of testing proposed interventions to see if they actually produce the anticipated effect in real-world settings.

There are important limitations to our findings. Although the sample of sentinel physicians surveyed was designed to be representative of AAP and AAFP memberships, the attitudes, experiences, and practices of sentinel physicians may not be fully generalizable. Additionally, although this survey had a high response rate, nonrespondents may have had different views than respondents. Physicians’ perceptions of why parents are requesting to spread out immunizations may not accurately reflect parents’ viewpoints. Most important, the survey relied on self-report rather than direct observation.

Our study points out the need for an evidence base to guide primary care physicians in efforts to increase timely vaccination. Given the amount of time discussions with vaccine-hesitant parents take, the inability to charge for extra visits focusing solely on such discussions, and competing demands in primary care, interventions that supplement the limited communication that can occur at well-child visits are also needed. Recent data suggest that vaccine discussions need to begin early in pregnancy because that is when vaccine decision-making begins, especially for parents who are hesitant about vaccines, and interventions during this period may be effective.^44,47,48 Social marketing methods could be used to target vaccine-hesitant parents who may be considering delaying vaccines before these decisions are made.⁴⁹ The importance of social networks in shaping parents’ vaccination decisions has been underlined and interventions targeting networks within a community could have broader impact.²⁵ Reinforcing vaccination as a social norm could be better leveraged as it has been in a variety of other health care interventions.^50–55 Amplifying the voice of the vast majority of parents who do follow vaccination recommendations in public messaging and in settings such as preschools and schools could be a powerful tool that, up to the present, has not been used on a large scale. Critically, to guide primary care and public health providers, we need to test any of these proposed approaches in real-world settings in comparative effectiveness trials with the outcome of actually increasing timeliness and completeness of vaccinations.