Douglas J. Opel, MD, MPH
Rita Mangione-Smith, MD, MPH
Jeffrey D. Robinson, PhD
John Heritage, PhD
Victoria DeVere, BS
Halle S. Salas, MPhil
Chuan Zhou, PhD
James A. Taylor, MD
Publication Date
October 1, 2015

University of Washington School of Medicine (Opel, Mangione-Smith, Zhou, Taylor); Portland State University (Robinson); University of California, Los Angeles (Heritage); Seattle Children's Research Institute (DeVere, Salas)

"Participatory communication formats for initiating vaccine recommendations appear to be associated with a highly rated visit experience and reduced parental vaccine acceptance."

This study investigated how provider vaccine communication behaviours influence parental vaccination acceptance and visit experience. The researchers previously identified 2 provider communication behaviours that appear to influence parental vaccine decision making: (i) When providers used participatory formats to initiate vaccine discussions (e.g., "What do you want to do about shots?"), parents were more likely to voice initial resistance to vaccines (e.g., "I don't want him vaccinated today") than when providers used presumptive formats (e.g., "We have to do some shots"). (ii) If patients voiced resistance, providers' pursuit of their original vaccine recommendations (e.g., "He really needs these shots") changed nearly half of parents' vaccination decisions. Yet questions remain. First, how is provider initiation format associated with parental vaccination acceptance at visit's end? Second, how do these communication behaviours influence other pertinent outcomes, such as parents' ratings of their visit experience? (There is concern that providers' use of presumptive formats to initiate vaccine discussions, despite precipitating less verbal resistance from parents during visits, may negatively affect parents' experiences and, in turn, may result in decreased vaccine uptake over time.)

In a cross-sectional observational study in the Puget Sound area in Washington State, United States (US), the researchers videotaped provider-parent vaccine discussions (n = 111). They dichotomised initiation formats into: presumptive formats, which presupposed that parents would vaccinate, and participatory formats, which provided parents more decision-making latitude. The researchers coded visits for the format providers used for initiating the vaccine discussion (participatory vs. presumptive), parental verbal resistance to vaccines after provider initiation (yes vs. no), and provider pursuit of recommendations in the face of parental resistance (pursuit vs. mitigated or no pursuit). Main outcomes were parental verbal acceptance of recommended vaccines at visit's end (all vs = ≥1 refusal) and parental visit experience (highly vs lower rated). Also, after their visits and before leaving the clinic, participating parents completed a self-administered survey.

Providers used presumptive formats to initiate vaccine discussions in 74% (n = 69) of encounters and participatory formats in 26% (n = 24). Parents voiced resistance after providers' initiation formats in 41% (n = 38) of encounters, and among these, providers pursued their original vaccine recommendations in 50% (n = 19). Overall, 64% of participating parents accepted all recommended vaccines at visits' end, and 72% rated their visit experience highly.

In multivariable models, participatory (vs. presumptive) initiation formats were associated with decreased odds of accepting all vaccines at visit's end (adjusted odds ratio [AOR] = 0.04; 95% confidence interval [CI] = 0.01, 0.15) and increased odds of a highly rated visit experience (AOR = 17.3; 95% CI = 1.5, 200.3). "Overall, it may be that participatory initiation formats are a better match for the development of an open, trusting relationship that parents - particularly vaccine-hesitant parents - desire to have with their children's providers....Providers may perceive a need to leverage the inherent value of participatory approaches in cultivating strong provider–parent relationships to help ensure parental vaccine acceptance over time at the expense of acceptance short term."

Among encounters in which parents voiced initial resistance but accepted all vaccines at visit's end (n = 14), providers pursued their original vaccine recommendations in all but 1 (93%), and all parents had voiced nonexplicit, rather than explicit, resistance to the provider's initiation. More providers pursued their original vaccine recommendations if they had used presumptive (vs. participatory) formats to initiate vaccine discussions (74% vs 26%; P = .003). The data suggest that a significant mediator of the pathway between provider initiation format and parental acceptance of all vaccines at visit's end is providers' pursuit after initial parental resistance.

In conclusion, in the context of 2 general communication formats used by providers to initiate vaccine discussions, there appears to be an inverse relationship between parental acceptance of vaccines and visit experience. Using presumptive formats that assume vaccination seems to increase acceptance but decrease visit experience, whereas using participatory formats that provide parents more decision-making latitude appears to do the opposite. Further exploration of this inverse relationship in longitudinal studies is recommended. However, in the meantime, the results suggest that pursuing vaccine recommendations may temper the negative effects that participatory initiation formats have on vaccine acceptance without any concomitant negative effects on parental experience. A commitment to pursuing parental resistance following the use of participatory initiation formats may therefore represent a communication strategy that attains both vaccine acceptance and parent satisfaction.


American Journal of Public Health, Vol. 105, No. 10, pgs. 1998-2004. Image credit: