Vaccine Hesitancy in Rural Pediatric Primary Care

"In the face of the coronavirus disease 2019 pandemic and virulent flu season of 2020, now is the time to arm providers with tools that educate and empower VHC to understand and believe that vaccines work, vaccines are safe, and vaccines are necessary."

Studies have documented a rise in the number of vaccine-hesitant caregivers (VHC) and declining childhood vaccine rates across various countries worldwide, including the United States (US). In part, this could be explained by the fact that caregivers have been concerned with the increasing number of injections being added to the schedule in the US, in the context of conflicting information on social media. The Parent Attitudes about Childhood Vaccines (PACV) survey is a standardised tool that identifies, measures, and classifies the concerns and needs of VHC and identifies the underlying determinants of hesitancy. The purpose of this quality improvement (QI) project was to determine if early identification of vaccine hesitancy (VH) using the PACV survey and targeted interpersonal communication interventions would decrease VH scores.

The sample included 70 caregivers of paediatric patients aged 2 months to 5 years presenting for well-child checks at a rural US paediatric primary care clinic that primarily serves low-income Hispanic and Latino patients. Participants were given the preintervention PACV survey on paper at check-in. The provider reviewed the presurvey results before the initiation of the visit to determine which intervention(s) would be appropriate. These included:

• Presumptive language model - All interactions began with the assumption that the caregiver would accept all recommended vaccines: "your child needs three shots today", compared with participatory language such as, "what do you think about your child getting their shots today?" If the caregiver expressed concern in response to the presumptive language cue, the provider would proceed by giving a confident yet caring recommendation. If the caregiver continued to demonstrate hesitancy, the provider listened and responded to their questions with the below two techniques.
• Motivational interviewing (MI) techniques - The provider's main goal is to be an active listener and reflect the caregiver's hesitations, demonstrating both respect and empathy to develop a trusting relationship further and to strengthen a caregiver's motivation to change their beliefs and behaviours regarding VH. For this approach, the provider used the OARS (open-ended, affirming, reflective listening, summarising) model for MI dialogue, which focused on understanding the caregiver's concerns in their own words and avoiding yes or no responses: "What can you tell me about your concerns regarding the vaccines your child will be receiving today?" Positive affirmation statements and gestures were given to promote confidence and trust, such as, "I appreciate that you've come with these questions today". The judgment-free stance was designed to increase VHC's willingness to learn and make changes in a positive direction. Reflective listening (e.g., "It sounds like your main concern is the ingredients in the vaccines; is this correct?") showed active engagement with the VHC's concerns and avoided assumptions.
• Education-based dialogue aimed at identifying underlying determinants of VH - The provider provided specific educational-based information to inform their concerns in an empathetic and concise manner as not to overwhelm or confuse the caregiver. The dialogue ended with an invitation to ask follow-up questions and an assessment of the VHC's willingness to change: "Did that address your concerns today? Would you like to move forward with the recommended vaccines?"

The presumptive language model was used for non-VHC participants. VHC participants received the following interventions: presumptive language model, MI, and education-based dialogue. After the intervention, clinical staff provided the participating caregiver with the postintervention PACV survey after the visit to assess for a decrease in VH scores.

Of the 70 participants, 11 were VH in the preintervention survey group; of those, 2 (18.2%) remained VH (p=.004) after the intervention.

Reflecting on the results, the researchers assert: "Routine monitoring with VH screening tools, such as the PACV survey, offers proactive measures of identifying VHC to decrease hesitations and increase pediatric vaccination rates. Presumptive language should be used when discussing the recommended pediatric vaccines to instill confidence and reassure caregivers of safe medical management. When necessary, MI and educational-based dialogue should be employed to advocate for caregiver acceptance of recommended vaccines....Given the increasing rate of VHC, it is imperative that health care providers are proactive, not reactive, in our efforts to avert the spread of vaccine-preventable diseases."

In terms of next steps, the researchers affirm the need for efforts to develop standardised, evidence-based guidelines and tools to improve and sustain vaccination rates, with an emphasis on simplified, accessible tools for medical staff to use when talking to VHC. Ideally, they say, medical organisations and governing bodies would include use of VH screening tools and intervention protocols in patient-centred medical home requirements. "Research studies that identify the significance of early screening and interventions to promote vaccination rates, such as this project, serve to advocate and inform larger-scale research endeavors to identify, intervene, and improve VH."