Physician Communication Training and

Parental Vaccine Hesitancy:

A Randomized Trial
Nora B. Henrikson, PhDa, Douglas J. Opel, MD, MPHb,c, Lou Grothaus, MSa, Jennifer Nelson, PhDa, Aaron Scrol, MAa,
John Dunn, MD, MPHa, Todd Faubion, PhDd, Michele Roberts, MPH, MCHESe, Edgar K. Marcuse, MD, MPHb,c,
David C. Grossman, MD, MPHa,c,f

abstract BACKGROUND AND OBJECTIVES: Physicians have a major inuence on parental vaccine decisions. We tested
a physician-targeted communication intervention designed to (1) reduce vaccine hesitancy in
mothers of infants seen by trained physicians and (2) increase physician condence in
communicating about vaccines.
METHODS: We conducted a community-based, clinic-level, 2-arm cluster randomized trial in Washington
State. Intervention clinics received physician-targeted communications training. We enrolled mothers of
healthy newborns from these clinics at the hospital of birth. Mothers and physicians were surveyed at
baseline and 6 months. The primary outcome was maternal vaccine hesitancy measured by Parental
Attitudes on Childhood Vaccines score; secondary outcome was physician self-efcacy in
communicating with parents by using 3 vaccine communication domains.
RESULTS: We enrolled 56 clinics and 347 mothers. We conducted intervention trainings at 30 clinics,
reaching 67% of eligible physicians; 26 clinics were randomized to the control group. Maternal
vaccine hesitancy at baseline and follow-up changed from 9.8% to 7.5% in the intervention group
and 12.6% to 8.0% in the control group. At baseline, groups were similar on all variables except
maternal race and ethnicity. The intervention had no detectable effect on maternal vaccine
hesitancy (adjusted odds ratio 1.22, 95% condence interval 0.472.68). At follow-up, physician
self-efcacy in communicating with parents was not signicantly different between intervention
and control groups.
CONCLUSIONS: This physician-targeted communication intervention did not reduce maternal vaccine
hesitancy or improve physician self-efcacy. Research is needed to identify physician
communication strategies effective at reducing parental vaccine hesitancy in the primary care
setting.

WHATS KNOWN ON THIS SUBJECT: Parental
hesitancy about childhood vaccines is prevalent
and related to delay or refusal of immunizations.
Physicians are highly inuential in parental vaccine
decision-making, but may lack condence in
addressing parents vaccine concerns.
WHAT THIS STUDY ADDS: A physician-targeted
communications intervention designed to reduce
maternal vaccine hesitancy through the parent-
physician relationship did not affect maternal
hesitancy or physician condence
communicating with parents. Further research
should determine the most effective approaches
to addressing vaccine hesitancy.
a
Group Health Research Institute, Seattle, Washington; bSeattle Childrens Research Institute, Seattle Childrens
Hospital, Seattle, Washington; cDepartments of Pediatrics, and fHealth Services, University of Washington, Seattle,
Washington; dWithinReach, Seattle, Washington; and eState of Washington, Department of Health, Seattle,
Washington
Dr Henrikson codesigned the study, directed all aspects of the trial, drafted all data collection
instruments, wrote the rst draft of the manuscript, and approved the nal manuscript as
submitted; Dr Opel rened the data collection instruments, assisted with analysis planning and
interpretation of results, drafted portions of the manuscript, and reviewed and rened manuscript
drafts; Mr Grothaus was responsible for clinic randomization, wrote the analysis plan, conducted all
analyses, drafted portions of the manuscript, and critically reviewed the manuscript; Dr Nelson
codeveloped the analysis plan, supervised nal analyses and critically revised the draft manuscript;
Mr Scrol oversaw the recruitment of hospitals, mothers, and clinics into the trial, led the day-to-day
conduct and delity of data collection, and critically reviewed the manuscript; Dr Dunn led the
intervention team, codesigned the intervention materials, contributed to study design, analysis
planning, and interpretation of results, and critically reviewed the manuscript; Dr Faubion
coordinated scheduling and conduct of trainings, served as the health educator on the intervention
team, codesigned the intervention materials, and critically reviewed the manuscript;

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ARTICLE PEDIATRICS Volume 136, number 1, July 2015
Many parents in the United States delay
or refuse vaccines recommended by the
Centers for Disease Control and
Prevention for young children.13 As
public condence in vaccines erodes,47
parents hesitate about vaccine
decisions, vaccination rates may
decrease, and outbreaks of vaccine-
preventable disease may be more
likely.811
Physicians are highly inuential on
parental beliefs and attitudes about
childhood vaccinations,7,1214 yet many
feel unprepared to address questions
from vaccine-hesitant parents.1517
Improved physician communication
with vaccine hesitant-parents
could address parental hesitancy, but
few evidence-based interventions are
available.18 We conducted
a randomized trial to test whether
a novel communication intervention
targeted at physicians could improve
physician condence in communication
and reduce vaccine hesitancy among
mothers of infants.
METHODS
We conducted a 2-arm clinic-level
cluster randomized trial in pediatric
and family practice outpatient clinics
from March 2012 to December 2013.
We hypothesized that training
physicians would improve their self-
efcacy in communicating with
parents about vaccines, which would
subsequently improve physician-
parent communication and positively
inuence parental attitudes and
beliefs about vaccines. All study
protocols were approved by
the Group Health Research Institute
Institutional Review Board. Hospital
recruitment activities were also
approved by the Western IRB.
Participants
Mothers
We recruited 4 hospitals with obstetric
and newborn services in 2 western
Washington counties (King and
Snohomish). Deliveries at these
hospitals constitute 44% of annual
deliveries in the counties. Study staff
PEDIATRICS Volume 136, number 1, July 2015
approached mothers in the postpartum
unit of these 4 hospitals, offered
information about the study, and
collected contact information
for interested mothers. Eligibility
criteria included planning to receive
routine well-child care from a study
clinic, age .18, English speaking, and
pregnancy .35 weeks of gestation.
Mothers were not approached if they or
their newborns had medical
complications.
Clinic Recruitment
All vaccines in Washington are obtained
through a central ordering system
administered by the Washington State
Department of Health. Clinics in study
counties that had ordered childhood
vaccine from this program in 2010
comprised our clinic sampling frame.
Clinic inclusion criteria included use of
a study hospital newborn nursery and
having ordered $1000 doses of
childhood vaccine in 2010. Exclusion
criteria included federally qualied
health centers, naturopathic-only
practices, or concurrent participation in
other vaccine-related studies by study
investigators. Physician investigators
contacted clinic leaders directly to
invite study participation. Clinic leaders
provided the individual contact
information for physicians at heir clinic
providing pediatric care. Clinic leaders
were asked to encourage physicians
to participate in the study data
collection and training. Providers did
not receive payment for participation in
the training or data collection.
Randomization and Blinding
We used the clinic as the unit of
randomization. Randomization was
blocked on medical group; single-site
clinics were collectively considered
a block. A biostatistician blinded to
clinic name and location carried out
randomization by using numeric
clinic identiers. Clinics could not
be blinded to their randomization
status, but clinics learned their status
only after their clinics baseline
data collection was complete. We did
not share information about any
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mothers participating in the trial with
any clinic staff.
Intervention
Intervention and Control Activities
Intervention clinics received training on
a novel communication strategy
developed by Vax Northwest,
a partnership in Washington State.19
The strategy, Ask, Acknowledge,
Advise, was adapted from effective
communication models,20 informed by
constructs from the theory of planned
behavior21,22 and based on best
practices in physician-patient
communication2325 adapted to vaccine
conversations. This strategy had been
shown to be feasible and well-received
in initial evaluation.19 According to
this strategy, the ask step cues
physicians to invite parental vaccine
questions and concerns, the
acknowledge step reinforces
communication of respect and empathy
for the parents concerns and creation
of a trusting environment, and the
advise step prompts physicians to
recommend immunization, educate
about the benets and risks of vaccines
and vaccine-preventable disease, and
end the consultation with a mutually
agreed on action such as vaccinating or
an appointment to discuss further.
The intervention was delivered by
using a modied academic detailing
format.26 The main component was a
45-minute training administered by
a pediatrician immunization expert
and a health educator. The entire
clinic staff was invited to the training;
food was provided. We tracked training
attendance by sign-in sheets. We did
not track the number of minutes
physician attendees spent in the
training.
The training included didactic
presentation of data on
vaccine hesitancy, the strong provider
inuence on parental vaccine
decisions, and the importance of trust-
building around vaccine decisions.
Interactive components included
facilitated discussion of videos
modeling the method and how clinic
71
ow could be adjusted to improve
vaccine hesitancy.
We considered intervention delity
achieved if the training was successfully
scheduled and carried out at its
intended length and content.27
Immediately after the training, each
attendee was invited to complete an
anonymous 1-page written evaluation
rating the following domains on
a scale of 1(poor) to 7 (excellent): how
well the presentation met objectives,
presentation quality, quality of written
materials, practical value of the subject
matter, value for practice, and overall
impression. We conducted descriptive
analyses of the results.
Second, training participants received
paper materials with consistent
branding (Lets Talk Vaccines)
detailing the framework. To reinforce
training messages and reach
nonattendees, each clinic received these
materials plus branded leave-behind
buttons, notepads, and parent-facing
resources. The health educator visited
each clinic 3 months after training and
provided branded mugs and more
supplies of training materials.
Third, each eligible physician,
regardless of training attendance,
received 6 months of monthly e-mail
newsletters, a link to the study Web site
that included a webinar version of the
training, and technical assistance on
request, such as responses to unusual
parent questions about vaccine safety.
Control clinics did not receive any of
these intervention components. After
data collection concluded at each
control clinic, the health educator
delivered the training materials and
offered study physicians access to
online training materials via the study
Web site.
Measures
Our primary study outcome was
maternal vaccine hesitancy at month
6, assessed by maternal score on the
Parental Attitudes on Childhood
Vaccines (PACV) survey. The PACV is
a 15-item scale with high reliability
72
and is associated with vaccine
behavior.2830 It assesses attitudes,
beliefs, and past vaccination
behaviors, and is scored from 0 (least
hesitant) to 100 (most hesitant)
with scores $50 considered
hesitant and $70 very hesitant.
Cronbach a for the items in the PACV
scale was 0.85. The survey also
included demographic items, vaccine
information sources, family vaccine
decision-maker, and duration of
relationship with infants physician.
We contacted mothers by phone at
infants age 4 to 6 weeks to conrm
consent and administer the baseline
survey; survey completion
constituted enrollment in the study. A
follow-up survey was conducted 6
months later. Surveys were
administered by trained interviewers
blinded to randomization status using
Sawtooth Ci3 (Sawtooth
Technologies, Inc, Northbook IL) and
WinCATI, a computer-assisted
telephone interviewing software.
Our secondary outcome was
physician condence in
communicating with parents about
childhood vaccines. We developed 6
single-item self-efcacy questions
about communicating with
parents about childhood vaccines, by
using a standard self-efcacy item
format (How condent are you in
your ability to),31,32 adapted from
those used previously by study
investigators. We selected 3 items
a priori as outcome measures (talking
about the risks of vaccines, providing
vaccine information resources, and
answering difcult parent questions
about vaccines), and 3 as hypothesis-
generating (overall condence about
communicating about vaccines,
establishing an ongoing dialogue, and
discussing the benets of vaccines).
The survey also assessed pediatric
practice volume, years in practice,
frequency of parental vaccine
concerns, and number of clinics in the
medical group.
We e-mailed eligible physicians
a unique link to a self-administered
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survey before clinic randomization
status was revealed, with up to 2
reminders. Completion of the survey
was considered to constitute the
physicians consent to participate
in the study. Baseline data collection
was terminated either before the
training date (intervention clinics)
or after 6 weeks (control clinics). Six
months later, the follow-up survey
was administered, by using the
same procedures, to all eligible
physicians regardless of whether
they had completed the baseline
survey or whether they had
attended training.
Data Analysis
Prerecruitment power calculations
assumed 50 clinics and 500 mothers
and a 25% baseline hesitancy rate,
representing 80% power to detect
a 12.4% difference in the percentage
of hesitant mothers at follow-up
between intervention and control
groups. To compare the baseline
characteristics of both physicians and
mothers in the 2 groups, we used
a generalized estimating equation
(GEE) version of a x2 test (for binary
or categorical variables) or a GEE
version of a t test (for ordinal or
continuous variables) to account for
within-clinic correlation. All
multivariable models were selected
a priori.
Maternal vaccine hesitancy at month
6, our primary study outcome, was
analyzed in 2 ways: as a dichotomous
measure as hesitant or
nonhesitant and as an ordinal
measure with 5 levels. We used GEE
logistic regression to do unadjusted
and adjusted analyses comparing
hesitancy in the intervention and
control groups. We also formed a 5-
level ordinal version with PACV
categories 0 to 20, 30 to 49, 50 to 59,
60 to 69, and 70 to 100. We used
a random effects proportional odds
model to estimate a common odds
ratio (OR) comparing the likelihood of
being at a higher hesitancy level
in the 2 groups to account for within-
clinic correlation. Because of sparse
HENRIKSON et al
FIGURE 1
Study ow diagram.

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PEDIATRICS Volume 136, number 1, July 2015 73
TABLE 1 Baseline Characteristics: Mothers the previous 6 months, and reported
Overall n = 391 Control Group Intervention P a frequency of parental vaccine
n = 198 Group n = 193 concerns. We also conducted a per-
n % n % n %
protocol analysis comparing self-
efcacy of physicians in the control
Age
,30 113 29 64 32 49 25 .15
group with only physicians in the
3034 149 38 72 36 77 40 intervention group attending
$35 129 33 62 31 67 35 a training.
Marital status
Single/widowed 38 10 21 11 17 9 .62
Married/partnered 352 90 177 89 175 91 RESULTS
Education
High school or less 39 10 15 8 24 12 .41 We approached 85 clinics, including 30
Some college 66 17 36 18 30 16 single-site practices and 55 that were
4-year college 146 37 77 39 69 36 part of multisite medical groups (Fig 1).
Postgraduate 139 36 70 35 69 36 We enrolled and randomized 56 clinics
Household income
(65.9%). We conducted trainings of
,$25 000 26 7 11 5 15 8 .94
$2550 000 48 13 24 12 24 13 intended length and content in all 30
$5075 000 49 13 31 16 18 10 clinics randomized to the intervention
$75100 000 81 21 42 22 39 21 group. Of the 265 physicians
.$100 000 176 46 87 45 89 48 seeing pediatric patients in the 30
Raceb
clinics, 179 (67.5%) attended a training
Asian 59 15 42 21 17 9 .01
African American 18 5 11 6 7 4 session, along with 198 others (18
PI/HI/other 15 4 9 5 6 3 midlevel providers, 54 nurses, and 126
White 297 76 135 69 162 84 other staff). The median number of
Hispanic origin 23 6 8 4 115 8 .04 total attendees was 16.5 (range 422)
No. children, mean (SD) 1.80 (0.88) 1.76 (0.83) 1.84 (0.93) .30
and of physician attendees was 6 (range
First-time parent 181 46 92 47 89 48 .99
Vaccine decision-maker 219). Among attendees, 278 (74%)
Mom only 82 21 44 22 38 20 .82 completed posttraining evaluations. The
Mom and someone else 307 79 153 77 154 80 proportion rating the training as 6 or 7
Other person 2 0.5 1 0.5 1 0.5 (7-point scale) ranged from 89.6%
Duration of relationship with
(value of training for my practice) to
infants doctor
,1 mo 62 16 38 20 24 13 .08 96% (presentation quality).
1 to 12 mo 132 34 64 33 68 35 A total of 471 physicians received
1 to 5 y 133 35 68 35 65 34
.5 y 58 15 23 12 35 18
invitations to the baseline survey, and
Vaccine information source (main) 285 (60.5%) completed surveys. We
Childs doctor 288 74 144 73 144 75 .35 sent 463 follow-up surveys; 290
All other sources 71 18 34 17 37 19 (62.6%) were completed. The nal
Internet 32 8 20 10 12 6 analysis set included 263 baseline
Vaccine hesitant (PACV) 44 11.3 25 12.6 19 9.8 .43
PACV scorec, mean (SD), 21.7 (18.0) 22.8 (18.7) 20.6 (17.3) .34
surveys (118 control; 145
intervention) and 211 month-6
HI, Hawaiian; PI, Pacic Islander.
a P value compares means in control and intervention group using a GEE t test: percentages are compared by using a GEE surveys (90 control, 121
x 2 test. intervention). We excluded 9 clinics
b Race P value compares % white.
c Scored 0100 (.50 considered hesitant),
from analysis because no mothers
could be linked to the clinics.
We approached 700 mothers and
data, we adjusted for only the compared control and intervention
enrolled 488 (69.7%). Of these, 391
baseline value of the PACV (coded by physicians reporting high self-efcacy
(80.1%) completed the baseline
using 2 dummy variables for 030 vs at follow-up, dened as 4 or 5 on a 1
survey and 347 mothers (71.1%)
to 5 scale. We used GEE x2 tests
3049 vs 50+) and race, which was completed the follow-up survey.
(unadjusted analysis) and GEE
correlated with hesitancy and
logistic regression for adjusted
differed in the 2 treatment groups. Baseline Characteristics
analyses. We controlled for baseline
Only physicians who reported seeing self-efcacy, physician gender, Mothers
infants in the previous 6 months were specialty (pediatrics versus family Mean maternal age was 32.2 years
included in the analysis. We practice), number of children seen in (SD 4.9), 90% were married or

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74 HENRIKSON et al
TABLE 2 Practice and Physician Characteristics
Overall Control Intervention P

n = 56 clinics n = 26 clinics n = 30 clinics

Clinic
No. of physicians, n (%)a 526 236 (45) 290 (55) .33
Clinics in medical group, n (%)a
1 6 (11) 2 (8) 4 (13) .87
23 0 (0) 0 (0) 0 (0)
35 2 (4) 1 (4) 1 (3)
$6 48 (86) 23 (88) 25 (83)
Practice type, n (%)a
Pediatrics only 18 (32) 9 (35) 9 (30) .89
Family medicine only 36 (64) 16 (62) 20 (67)
Mixed pediatric/family medicine 2 (4) 1 (4) 1 (3)
Childhood vaccine volume, dosesb
Median (IQR) 5488 (325012 005) 5208 (270013 415) 5618 (361010 740) .78
Physician samplec n = 263 physicians n = 118 physicians n = 145 physicians
Professional degree, n (%)
DO 6 (2) 3 (3) 3 (2)
MD 257 (98) 115 (97) 142 (98) .81
Specialty, n (%)
Family medicine 152 (58) 56 (48) 96 (67) .16
Pediatrics 109 (41) 61 (52) 48 (33)
Women, n (%) 174 (66) 76 (64) 98 (68) .58
Years since medical school graduation, n (%)
#10 55 (21) 16 (14) 39 (27) .07
1120 92 (35) 46 (39) 46 (32)
2130 74 (28) 33 (28) 41 (28)
.30 42 (16) 23 (19) 19 (13)
Mean (SD) 18.9 (10.2) 20.2 (10.2) 17.7 (10.1) .12
No. of children 024 mo seen per week in past 6 mo, n (%)
14 74 (28) 31 (26) 48 (33) .25
512 59 (22) 22 (19) 37 (26)
1325 46 (17) 17 (14) 29 (20)
.25 84 (32) 48 (41) 36 (25)
Mean 2.53 (1.21) 2.69 (1.25) 2.4 (1.16) .28
Frequency of parental childhood vaccine concerns in
previous 6 mo, n (%)
Always/frequently 89 (34) 44 (37) 45 (31) .27
Sometimes 117 (44) 53 (45) 64 (44)
Never/rarely 57 (22) 21 (18) 36 (25)
No. of clinics in medical group, n (%)
1 42 (16) 10 (9) 32 (22) .35
25 26 (10) 9 (8) 17 (12)
6 or more 192 (74) 98 (84) 94 (66)
DO, Doctor of Osteopathic Medicine; IQR, interquartile range; MD, Doctor of Medicine.
a Publicly available data, accessed 2010.
b Source: Washington State Department of Health, vaccine ordering data, 2012.
c Assessed by self-administered survey.

partnered, and 73% were college
graduates or higher. Nearly half
(46%) reported a household income
of $$100 000. The intervention
group was more likely to report
White race (84% vs 69%, P = .01) and
less likely to report Hispanic ethnicity
(4% vs 8%, P = .04). Nearly half of the
sample was rst-time parents (46%);
the mean number of children was 1.80
(SD 0.88) (Table 1). Most (79%)
reported joint decision-making about
vaccines with another person. Sixteen
percent reported they had known their
infants doctor for ,1 month;
an additional one-third, for ,1 year but
.1 month. The most common source
of vaccine information was the infants
doctor (74%).
Eleven percent (n = 44) of the
sample was vaccine hesitant at
baseline (12.6% control; 9.8%
intervention; P = .43); mean PACV
score was 21.7 (SD 18.0) (Table 1).
Eight mothers (2%) had PACV scores
in the very hesitant range.
Clinic and Physician Characteristics
Most clinics were part of medical
groups with $6 sites and were family
medicine clinics (Table 2). These
clinics represented a total of 526
study-eligible physicians. Of the
participating physicians (n = 263),
nearly all had a Doctor of Medicine
degree and two-thirds were women.

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PEDIATRICS Volume 136, number 1, July 2015 75
Nearly half (48%) of physicians in the ,30) was similar between groups at DISCUSSION
control group reported a family both baseline and follow-up: 70.7% and We conducted a cluster randomized
medicine specialty compared with 74.6% of mothers in the control controlled trial to test the impact of
67% of the intervention group (P = and intervention groups, respectively, a novel intervention to address
.16). Intervention clinic physicians and 79.9% and 79.8% at follow-up.
parental hesitancy by improving
reported slightly fewer years since Adjusting for baseline PACV and race
physician-parent communication
medical school graduation (P = .07). had little effect on the ordinal results
about early childhood vaccines. Both
At baseline, both control and (OR 1.13, 95% CI 0.612.10, P = .60).
unadjusted and adjusted results
intervention group physicians
indicate that the intervention neither
reported that parents in their practice Secondary Outcome: Physician Self-
reduced maternal hesitancy nor
always, frequently, or sometimes Efcacy
improved physician condence in
voiced vaccine concerns in the Baseline physician self-efcacy was addressing parental hesitancy.
previous 6 months (82% and 75%, lower in the intervention group
respectively). (Table 4). Compared with the control Vaccine hesitancy continues to be
group, fewer physicians in the a difcult problem to address.33 A
Primary Outcome: Maternal Vaccine systematic review found limited
Hesitancy intervention group reported high
condence in talking about risks evidence for the impact of any
The intervention had no effect on (58% vs 70%, P = .06), providing intervention on improving vaccine
maternal vaccine hesitancy information (69% vs 81%, P = .03), acceptance, and none focused on the
(Table 3). At follow-up, 8.0% (13) and answering difcult parent physician-patient relationship
of the control group and 7.5% (14) questions (54% vs 69%, P = .01). pathway.18 This study is, to our
of the intervention group were After adjusting for baseline self- knowledge, the rst randomized trial
vaccine hesitant (P = .78). Adjusting efcacy, the intervention had no to test an intervention aimed at
for baseline PACV score and race effect on physician self-efcacy at improving hesitancy about early
showed similar results (OR 1.22, month 6 on any of the 3 items; fully childhood vaccines by working
95% condence interval [CI] adjusted models showed similar directly with physicians.
0.472.68; OR .1.0 indicates results. The 3 exploratory items
greater hesitancy in the Our study had a strong design. We
suggested similar results. Per- identied and approached a large,
intervention group). protocol analysis of physicians in the community-based sample of clinics.
Summarizing the PACV as an ordinal intervention group attending We had high consent, response, and
measure showed similar results a training showed no difference in
follow-up rates. The Ask,
(Fig 2). The percentage of mothers at self-efcacy for any of the 6 items
Acknowledge, Advise communication
lower levels of hesitancy (PACV score (data not shown).
framework, the centerpiece of our
intervention, was based on best
TABLE 3 Maternal Vaccine Hesitancy: Results practices, pretested, delivered in
Control, n (%) Intervention, n (%) ORa (P ) Adjusted ORb a format known to change physician
(95% CI) behavior, carried out as intended,
Baseline Month 6 Baseline Month 6
and well-received.
Vaccine hesitant, %
PACVc The null effect we observed may have
50100 25 (12.6) 14 (8.0) 19 (9.8)d 13 (7.5) 0.93 (.78) 1.22e (0.472.68)f been due to intervention reach. Only
Vaccine hesitant, ordinal 67% of the target physician
PACVg
029h 140 (70.7) 139 (79.9) 144 (74.6)i 138 (79.8) 0.95 (.86) 1.13 (0.612.10)j
population attended training, but all
3049 33 (16.7) 21 (12.1) 30 (15.5) 22 (12.7) were given access to an online
5059 15 (7.6) 6 (3.4) 13 (6.7) 8 (4.6) version of the training and resources
6069 5 (2.5) 4 (2.3) 3 (1.6) 2 (1.2) and e-mailed repeatedly with
70+ 5 (2.5) 4 (2.3) 3 (1.6) 3 (1.7)
information, technical support, and
a OR for difference in month 6 hesitancy between intervention and control groups.
b Adjusted for baseline PACV hesitancy score and race (2 indicator variables for white, Asian, and all other races).
reinforcement of intervention
c PACV, score 50100. Estimated with GEE logistic regression with empirical SEs. messages. We do not know how many
d OR for baseline difference between groups 0.76 (P = .43) (Table 1).
intervention physicians used the
e OR .1.0 corresponds to a higher hesitancy rate in the intervention group.
f P = .71 online training or whether physicians
g Proportional odds regression with mixed effects to account for within-clinic correlation. ORs estimate the odds of being attended only partial in-person
at a higher hesitancy category. training. Therefore, mothers could
h PACV, scores 0100 where 100 is most hesitant; $50 indicates vaccine hesitancy.
i OR for baseline difference between groups: 0.78 (P = .42). have encountered an untrained
j P = .60. physician. However, the intervention

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76 HENRIKSON et al
 in provider-parent communication
lead to subsequent improvement in
100% maternal vaccine attitudes.
90% Communication is increasingly
recognized as a possible
80% determinant of health outcomes, by
70% increasing trust, patient knowledge,
PACV scores (ordinal)
satisfaction, and patient-centered
60% 70100 (most hesitant) experience.36 Maternal trust in
50% 6069 vaccine information, trust in the
5059 (hesitant) childs physician, and ability to
40% discuss vaccine concerns openly
3049
30% with the physician were all
029 (least hesitant)
measured in the PACV. Given the
20% null effect on maternal vaccine
10% hesitancy, we have limited ability to
assess where the intervention may
0% have fallen short in its
Control Intervenon Control Intervenon
implementation without other
Baseline Month 6 measures of physician attitudes or
FIGURE 2 behavior in clinical interactions
Vaccine hesitancy at baseline and month 6. with the study parent.
We acknowledge several limitations.
The prevalence of maternal vaccine
was designed to translate change and may require a higher-
hesitancy was less than expected, and
meaningfully into practice and thus intensity activity.34 Also, more recent
decreased in both the intervention
may reect realistic implementation data suggest that a strong physician
and control groups. During the study
of interventions of this type. recommendation may inuence
period, a highly publicized pertussis
Another reason for our null nding parents vaccine choices in the short
epidemic that involved infant
may be insufcient intervention term.35 Our intervention stressed the
deaths37 and a new state law
intensity. Despite 6 months of importance of physician
requiring a health care providers
reinforcement of the training recommendation, but focused more
signature to claim vaccine exemption
messages, our intervention in effect on long-term relationship building.
for school entry38 may have altered
was a 1-dose, 45-minute training. Finally, the intervention and study vaccine hesitancy in the study
Physician behavior is difcult to design relied on having improvement population, but it is unlikely the

TABLE 4 Physician Self-efcacy Results

Control % Intervention % Model 1a Model 2b
OR (P ) OR (95% CI)
Baseline, n = 118 Month 6, n = 90 Baseline, n = 145 Month 6, n = 121
How condent are you in your ability toc
1. talk about the risks of vaccines? 70 78 58d 76 1.47 (.13) 1.19 (0.751.49)
2. provide vaccine information resources? 81 79 69e 77 1.21 (.67) 1.22 (0.473.17)
3. answer difcult parent questions about vaccines? 69 74 54f 71 1.07 (.86) 1.13 (0.562.30)
Exploratory items:
Communicate with parents about vaccines? 91 91 81g 92 1.39 (.57) 1.17 (0.492.93)
Establish an ongoing dialogue about vaccines? 86 85 79h 92 3.52 (.03) 3.49 (1.0911.36)
Talk about the benets of vaccines? 97 94 95i 96 1.41 (.61) 1.88 (0.556.47)
a Adjusted for baseline self-efcacy only.
b Adjusted for baseline self-efcacy, gender, specialty, number of children seen per week.
c Self-efcacy stem; 45 on 5-point scale considered high self-efcacy.
d Baseline difference between groups (P = .06).
e Baseline difference between groups (P = .03).
f Baseline difference between groups (P = .01).
g Baseline difference between groups (P = .04).
h Baseline difference between groups (P = .13).
i Baseline difference between groups (P = .69).

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PEDIATRICS Volume 136, number 1, July 2015 77
intervention and control groups were
differentially exposed to these events.
There were also baseline differences
in the racial and ethnic distribution of
mothers, perhaps related to our use
of block randomization of clinics.
Although we adjusted for this in our
analyses, there may be other
unmeasured differences between the
intervention and control groups.
Finally, vaccination behavior would
have been the ideal primary
outcome,39 but it was logistically
infeasible. Because overall
early childhood vaccine coverage still
exceeds 90% in most areas, detecting
further improvement in vaccination
rates would require a sample size of
nearly 300 clinics. Thus, we chose an
intermediate measure that correlates
with vaccination behavior, but we
cannot assess if the intervention had
any impact on actual vaccination
behavior through any other, parents, and delivering feasible, high-
unmeasured intermediate pathway. dose communications interventions
We offer several recommendations with physicians where the ultimate
for future research. First, work in target is parent behavior.
identifying and targeting
interventions at hesitant parents may
CONCLUSIONS
be warranted. The relative impact of
vaccine hesitancy on vaccine A physician-targeted communications
coverage compared with other intervention was not effective in
factors, including access and beliefs changing maternal vaccine hesitancy
specic to cultural groups, deserves from birth to 6 months or in improving
further study. Increasing intervention physician condence in communicating
intensity through multiple levels of with parents.
inuence may yield better results; for
example, communication training
combined with clinic, systems, peer- ABBREVIATIONS
to-peer, or policy-level interventions CI: 95% condence interval
may have a greater collective GEE: generalized estimating
impact on maternal condence in equation
vaccines. Also, more foundational and OR: odds ratio
conceptual work is needed on the PACV: Parental Attitudes on
optimal approaches to Childhood Vaccines
communicating with vaccine-hesitant

Ms Roberts contributed to study design, codesigned the intervention materials, facilitated the identication of eligible study clinics, and critically reviewed the
manuscript; Dr Marcuse contributed to study design, analysis planning, and interpretation of results, assisted with clinic recruitment, codesigned intervention
materials, and critically reviewed the manuscript; and Dr Grossman conceptualized the study design, codesigned all data collection instruments, participated in
analysis planning and interpretation of results, and critically reviewed all manuscript drafts.
This trial has been registered at www.clinicaltrials.gov (identier NCT01667354).
www.pediatrics.org/cgi/doi/10.1542/peds.2014-3199
DOI: 10.1542/peds.2014-3199
Accepted for publication Mar 18, 2015
Address correspondence to Nora Henrikson, PhD, Group Health Research Institute, 1730 Minor Ave, Ste 1600; Seattle WA 98101. E-mail: henrikson.n@ghc.org
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright 2015 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no nancial relationships relevant to this article to disclose.
FUNDING: Supported by Group Health Foundation, Seattle, Washington.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found on page 180, and online at www.pediatrics.org/cgi/doi/10.1542/peds.2015-1382.

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 Physician Communication Training and Parental Vaccine Hesitancy: A
Randomized Trial
Nora B. Henrikson, Douglas J. Opel, Lou Grothaus, Jennifer Nelson, Aaron Scrol,
John Dunn, Todd Faubion, Michele Roberts, Edgar K. Marcuse and David C.
Grossman
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DOI: 10.1542/peds.2014-3199
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright 2015 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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 Physician Communication Training and Parental Vaccine Hesitancy: A
Randomized Trial
Nora B. Henrikson, Douglas J. Opel, Lou Grothaus, Jennifer Nelson, Aaron Scrol,
John Dunn, Todd Faubion, Michele Roberts, Edgar K. Marcuse and David C.
Grossman
Pediatrics 2015;136;70; originally published online June 1, 2015;
DOI: 10.1542/peds.2014-3199

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/136/1/70.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2015 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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