Elsevier

Social Science & Medicine

Volume 159, June 2016, Pages 100-107
Social Science & Medicine

Collaborative patient-provider communication and uptake of adolescent vaccines

https://doi.org/10.1016/j.socscimed.2016.04.030Get rights and content

Highlights

  • Some adolescent vaccination rates do not meet national guidelines.

  • Leveraging patient-provider communication could increase vaccination.

  • Vaccination was higher when parents reported receiving providers' recommendations.

  • Vaccination was higher when parents reported more provider-driven communication.

  • Efficient communication was rare but effective at increasing uptake.

Abstract

Rationale

Recommendations from healthcare providers are one of the most consistent correlates of adolescent vaccination, but few studies have investigated other elements of patient-provider communication and their relevance to uptake.

Objective

We examined competing hypotheses about the relationship of patient-driven versus provider-driven communication styles with vaccination.

Methods

We gathered information about vaccine uptake from healthcare provider-verified data in the 2010 National Immunization Survey-Teen for tetanus, diphtheria, and pertussis (Tdap) booster, meningococcal vaccine, and human papillomavirus (HPV) vaccine (initiation among females) for adolescents ages 13–17. We categorized communication style in parents' conversations with healthcare providers about vaccines, based on parents' reports (of whether a provider recommended a vaccine and, if so, if conversations were informed, shared, or efficient) (N = 9021).

Results

Most parents reported either no provider recommendation (Tdap booster: 35%; meningococcal vaccine: 46%; and HPV vaccine: 31%) or reported a provider recommendation and shared patient-provider communication (43%, 38%, and 49%, respectively). Provider recommendations were associated with increased odds of vaccination (all ps < 0.001). In addition, more provider-driven communication styles were associated with higher rates of uptake for meningococcal vaccine (efficient style: 82% vs. shared style: 77% vs. informed style: 68%; p < 0.001 for shared vs. informed) and HPV vaccine (efficient style: 90% vs. shared style: 70% vs. informed style: 33%; p < 0.05 for all comparisons).

Conclusion

Efficient communication styles were used rarely (≤2% across vaccines) but were highly effective for encouraging meningococcal and HPV vaccination. Intervention studies are needed to confirm that efficient communication approaches increase HPV vaccination among adolescents.

Introduction

National guidelines recommend that adolescents routinely receive three vaccines: tetanus, diphtheria, and pertussis (Tdap) booster, meningococcal vaccine, and human papillomavirus (HPV) vaccine (Centers for Disease Control and Prevention (CDC), 2015b). Healthy People 2020 (Department of Health and Human Services, 2015) set the goal of 80% coverage for each of these vaccines among 13- to 15-year-old adolescents. As of 2014, vaccination coverage among all adolescents (ages 13 to 17) surpassed this benchmark for Tdap booster (88%), fell somewhat short for meningococcal vaccine (79%), and was far from desired targets for HPV vaccine (40% for 3-dose completion among females) (Reagan-Steiner et al., 2015). Primary healthcare providers are central to efforts to increase adolescent vaccination.

Healthcare exists in a social context, and previous research has highlighted the potent influence of primary care providers' recommendations on uptake of vaccines (Dorell et al., 2013, Small et al., 2013). Healthcare is characterized by steep power imbalances between providers and patients. In such settings, patients often look to providers for expert advice and care. Providers' recommendations act as a cue to action (Hochbaum, 1958, Skinner et al., 2015), a potent, timely intervention, since vaccines are available on the spot in many healthcare providers' offices and practices. Few studies have gone beyond examining provider recommendations to assess the potential impact of how providers and patients talk about vaccines. In the context of adolescent vaccines, when patients are generally ages 10–17, parents also are part of the conversation; thus, when we refer to “patients,” we include adolescents and their parents or other caregivers.

A useful framework for understanding these patient-provider interactions is the collaborative communication continuum proposed by Charles et al., 1997, Charles et al., 1999 and Murray et al. (2006). Generally, this continuum captures different modes of communication according to how patient- or provider-driven the conversation is across three dimensions: information exchange, deliberation, and deciding on which treatment to implement. A patient-driven conversation, called “informed,” involves one-way information flow from provider to patient (theoretically giving the patient all the information needed to make an informed decision independently), but deliberating and deciding on a treatment option is completely the patient's responsibility. The opposite extreme on this continuum is a provider-driven conversation, called “paternalistic,” which involves one-way information flow from provider to patient (perhaps only the minimum amount required for a patient to be able to give consent), but deliberating and deciding on a treatment option is completely the provider's responsibility. Finally, a mid-point on the continuum is collaboration between patient and provider, called “shared,” which involves two-way exchange of information and joint efforts to deliberate and decide on a treatment option (Charles et al., 1999).

Researchers in public health and healthcare have examined the acceptability of some of these communication styles, primarily regarding shared and paternalistic styles. Shared patient-provider communication, which has become more accepted in the last few decades, honors patients' decision-making autonomy (Levinson et al., 2010, Lidz et al., 1988, Quill and Brody, 1996, Vermeersch, 1999, Whitney et al., 2004), especially when healthcare options are complex and/or lack professional consensus (Braddock et al., 1997, Braddock et al., 1999, Elwyn et al., 1999, Tzeng et al., 2010). In the context of routine vaccinations, bidirectional information exchange and joint deliberation and decision making can be particularly useful. Parents often report needing more information before consenting to their children receiving vaccines (Bartlett and Peterson, 2011, Gust et al., 2005). Shared communication allows providers to give information in a way that addresses patients' values (Bartlett and Peterson, 2011, Charles et al., 1999). Use of a shared communication style has been associated with improved clinical outcomes, such as better medication adherence (Coletti et al., 2012, Francis et al., 1969) and diabetes self-management (Rathert et al., 2013).

In contrast, paternalistic communication maps on to a traditional model for patient-provider interactions. This technique is time-efficient (Lidz et al., 1988, Tenrreiro, 2005) and highly acceptable to (and even preferred by) many patients (Arora and McHorney, 2000). Ethicists and medical scholars have suggested that a paternalistic communication approach is acceptable when providers and patients consider healthcare options that are minimally invasive, highly efficacious, and marked by professional consensus (Braddock et al., 1999, Whitney, 2003, Whitney et al., 2004), such as routine vaccinations. A paternalistic communication style may lead to fewer parents opting out of vaccination for their children (Hughes et al., 2011, Opel et al., 2013). For example, Opel et al. (2015) found that 74% of parents accepted flu vaccinations for their infants if providers used paternalistic (or “directive”) communication styles versus 4% of parents whose providers used patient-driven collaborative styles. However, it is unclear whether these results generalize to adolescent vaccinations.

Drawing upon research discussed in the previous section, we formulated three hypotheses about the relationships between patient-provider communication and uptake of adolescent vaccines.

First, we hypothesized that provider recommendations for vaccination would be positively associated with uptake (Hypothesis 1). Physicians have specialized and extensive training, may have ongoing relationships with adolescent patients and their families, and are well trusted. Thus, adolescents and their parents may be likely to follow the advice of their providers when making vaccination decisions. Across the adolescent vaccination literature, provider recommendation is one of the strongest and most consistent correlates of uptake, likely because it is a behavioral cue (Hochbaum, 1958, Skinner et al., 2015) and the means for action (opportunity, capability, and motivation) (Michie et al., 2011) are all present. Thus, we expected to find a similar relationship in our study.

Next, we proposed two competing hypotheses regarding the direction of the association between communication style and vaccination. It is unclear what communication style (informed versus shared versus paternalistic) is the best way for providers to communicate with parents in order to achieve high vaccine acceptance. All three approaches are characterized by unique strengths and weaknesses, and previous empirical studies have found evidence of relationships between shared and paternalistic styles and improved healthcare outcomes.

We hypothesized that more patient-driven communication styles would be associated with higher adolescent vaccination than other types of communication (Hypothesis 2). Patient-driven communication offers parents and adolescents adequate time to process information about vaccination and gives providers the opportunity to persuade vaccine-hesitant parents. This style of communication also respects the decision-making authority of adolescent patients and their parents, and it could increase their trust and satisfaction with healthcare providers. These processes could lead to higher vaccination compared to a more provider-driven communication style.

Finally, to compete with Hypothesis 2, we hypothesized that more patient-driven communication styles would be associated with lower adolescent vaccination than other types of communication (Hypothesis 3), a relationship demonstrated in the context of infant vaccination (Opel et al., 2013). In patient-driven communication, deliberating and deciding on a treatment option is partly or completely the responsibility of adolescents and their parents. This approach affords parents and adolescents more opportunities to object and opt out of vaccination. Patient-driven communication may also suggest professional ambivalence about vaccination or that vaccination is not routine, and as a result, problematize and discourage vaccination. These processes could lead to lower vaccination compared to a more provider-driven communication style.

Section snippets

Procedures

Data came from the 2010 National Immunization Survey (NIS)-Teen, implemented by the CDC (2015a). NIS-Teen included phone interviews with a national sample of caretakers of 13- to 17-year-old adolescents (hereafter called “parents”), during which parents reported the vaccination history of a randomly-selected adolescent in the household. At the end of the interview, NIS-Teen staff asked for consent to contact adolescents' primary healthcare providers to verify vaccination history with written

Results

Adolescents were nearly evenly split between male (52%) and female (48%) (Table 1). Most adolescents were non-Hispanic white (60%), and 61% had private health insurance. Vaccination among this sample was similar to rates of uptake for the entire population in 2010 (Centers for Disease Control and Prevention (CDC), 2011): 73% of adolescents had received Tdap boosters, 66% had received meningococcal vaccines, and 49% of female adolescents had initiated HPV vaccination.

For Tdap booster, 35% of

Discussion

Dimensions of communication between providers and patients, including recommendation and style, are important for achieving high levels of adolescent vaccine coverage. In a nationally-representative sample of U.S. adolescents, we found evidence of consistent positive associations between provider recommendations and vaccine uptake, and, for meningococcal and HPV vaccines, between more provider-driven communication styles and vaccine uptake. Indeed, the highest rates of vaccine uptake emerged in

Conclusions

In conclusion, uptake of adolescent vaccines was higher when parents reported that providers recommended the vaccines and, for meningococcal and HPV vaccines, that they used provider-driven communication styles (i.e., shared and efficient communication). Both dimensions of patient-provider communication were associated with high levels of vaccination that approached or surpassed Healthy People 2020 goals for Tdap booster and meningococcal vaccination (Department of Health and Human Services,

Conflicts of interest

JLM and BKR have no conflicts of interest to disclose. PLR has received a research grant from Merck Sharp & Dohme Corp. PLR has also received a research grant from Cervical Cancer-Free America, via an unrestricted educational grant from GlaxoSmithKline. NTB has served on paid advisory boards or received research grants from Merck, GSK, CDC, and FDA, and now serves as chair of the CDC-funded National HPV Vaccination Roundtable. These entities had no role in the study design, data analysis, or

Funding source

This study was supported by an NIH grant (F31 CA189411; PI: Moss). The funder had no role in study design; in the collection, analysis, and interpretation of data; in writing the manuscript; or in the decision to submit it for publication.

Acknowledgments

We thank Dr. Melissa Gilkey for her help in conceptualizing the paper. The research in this article was conducted while JLM was a Special Sworn Status researcher of the U.S. Census Bureau at the Center for Economic Studies. All results have been reviewed by the National Center for Health Statistics to ensure that no confidential information is disclosed. Research results and conclusions expressed are those of the authors and do not necessarily reflect the views of the National Cancer Institute

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