Previsit Screening for Parental Vaccine Hesitancy: A Cluster Randomized Trial.

OBJECTIVE: To evaluate the effect of vaccine hesitancy screening on childhood vaccine uptake. METHODS: We conducted a cluster randomized controlled trial in pediatric primary care clinics in Washington state. Vaccine-hesitant parents (VHPs) with a healthy newborn receiving health supervision at participating clinics were eligible. VHPs were identified by using a 4-item version of the validated Parent Attitudes About Childhood Vaccines Survey (PACV). Before their child's 2- and 6-month health supervision visits, VHPs at intervention clinics completed the 15-item PACV embedded in a survey containing placebo items. Intervention providers received a summary of parents' 15-item PACV responses and interpretation of their PACV score; discretion was given to providers regarding how they acted on this information. VHPs at control clinics completed only the placebo survey items, and their child's provider received a summary of their responses; control providers remained blinded to parent VHP status. Our outcome was child immunization status at 8 months of age expressed as percent of days underimmunized. We compared outcomes in control and intervention participants using t test and linear mixed-effects regression. RESULTS: We enrolled 24 clinics (12 in each arm) and 156 parents (65 in the intervention arm). Parent characteristics were similar across arms except more intervention (versus control) parents had a first-born child (60.9% vs 44%; P = .04). No significant difference in outcome was detected between arms (25.2% [95% confidence interval: 16.0% to 34.5%] vs 19.1% [95% confidence interval: 12.0% to 26.3%] mean days underimmunized in the intervention and control arms, respectively). CONCLUSION: Vaccine hesitancy screening was not significantly associated with days underimmunized.

Caregiver Experience in Pediatric Dialysis.

BACKGROUND AND OBJECTIVES: Pediatric dialysis is thought to be burdensome on caregivers given their need to assume dual responsibilities of parental and medical management of their child's chronic illness. In this study, we seek to describe the experience of parental caregivers of children receiving chronic dialysis for end-stage kidney disease. METHODS: We performed semistructured interviews of primary caregivers of children with end-stage kidney disease receiving chronic peritoneal dialysis or hemodialysis for at least 8 weeks from March 2016 to April 2017 at 3 pediatric dialysis centers in the United States. We performed a thematic analysis to inductively derive and identify themes and subthemes related to positive and negative caregiver experiences. RESULTS: Thirty-five caregivers completed interviews. Four major themes were identified, each with several subthemes: (1) caregiver medicalization (subthemes: diagnosis and initiation, disease management, and the future), (2) emotional adjustment (initial and/or acute phase, acceptance, personal growth, and medical stress and psychological burden), (3) pragmatic adaptation (disruption, adaptation of life goals and/or sense of self, and financial impact), and (4) social adjustment (relationship opportunity, relationship risk, advocacy, family functioning, and intimate relationships). These themes and subthemes reflected a broad range of experiences from positive to severely burdensome. CONCLUSIONS: Caregivers of patients on dialysis report a broad range of positive and burdensome experiences. These results reveal a need for continued advocacy to support families with a child on dialysis and can be used to develop targeted measures to study and improve caregiver experience in this population.

Parental Vaccine Hesitancy and Declination of Influenza Vaccination Among Hospitalized Children.

OBJECTIVES: Parents frequently decline the influenza vaccine for their child during hospitalization. In this study, we aimed to assess the role of vaccine hesitancy in these declinations. METHODS: This cross-sectional survey study was conducted among English-speaking parents of influenza vaccine-eligible children who were hospitalized between October 2014 and April 2015. Between July 2015 and September 2015, parents were recruited via mail to complete the validated Parent Attitudes about Childhood Vaccines (PACV) survey (modified for influenza vaccination). PACV scores (0-100 scale) were dichotomized into scores of ≥50 (hesitant) and <50 (nonhesitant). The primary outcome was parental declination of the influenza vaccine for their child during hospitalization. A secondary outcome was the declination reason documented during hospitalization. The main independent variable was parental vaccine hesitancy status, determined by the PACV score. Multivariable logistic regression was used to examine the association between vaccine hesitancy and influenza vaccine declination, adjusting for sociodemographic, visit, and clinical characteristics. The relationship between vaccine hesitancy and declination reason was also explored. RESULTS: Of 199 parents (18% response rate), 24% were vaccine hesitant and 53% declined the influenza vaccine for their child during hospitalization. Vaccine hesitancy (versus nonhesitancy) was associated with declining influenza vaccination (adjusted odds ratio: 6.4; 95% confidence interval: 2.5-16.5). The declination reason differed by vaccine hesitancy status, with a higher proportion of parents who were hesitant versus nonhesitant reporting "vaccine concern" or "vaccine unnecessary." CONCLUSIONS: Vaccine hesitancy was prevalent in this limited sample of parents of hospitalized children and associated with influenza vaccine declination. Additional investigation in a large, diverse, prospectively recruited cohort is warranted given the potential sampling bias present in this study.

Impact of Childhood Vaccine Discussion Format Over Time on Immunization Status.

OBJECTIVE: Presumptive formats to initiate childhood vaccine discussions (eg, "Well, we have to do some shots") have been associated with increased vaccine acceptance after one visit compared to participatory formats (eg, "How do you feel about vaccines?"). We characterize discussion format patterns over time and the impact of their repeated use on vaccine acceptance. METHODS: We conducted a longitudinal prospective cohort study of children of vaccine-hesitant parents enrolled in a Seattle-based integrated health system. After the child's 2-, 4-, and 6-month visits, parents reported the format their child's provider used to begin the vaccine discussion (presumptive, participatory, or other). Our outcome was the percentage of days underimmunized of the child at 8 months old for 6 recommended vaccines. We used linear regression and generalized estimating equations to test the association of discussion format and immunization status. RESULTS: We enrolled 73 parent-child dyads and obtained data from 82%, 73%, and 53% after the 2-, 4-, and 6-month visits, respectively. Overall, 65% of parents received presumptive formats at ≥1 visit and 42% received participatory formats at ≥1 visit. Parental receipt of presumptive formats at 1 and ≥2 visits (vs no receipt) was associated with significantly less underimmunization of the child, while receipt of participatory formats at ≥2 visits was associated with significantly more underimmunization. Visit-specific use of participatory (vs presumptive) formats was associated with a child being 10.1% (95% confidence interval, 0.3, 19.8; P = .04) more days underimmunized (amounting to, on average, 98 more days underimmunized for all 6 vaccines combined). CONCLUSIONS: Presumptive (vs participatory) discussion formats are associated with increased immunization.

Informed consent in pediatric anesthesiology.

BACKGROUND: Informed consent for pediatric anesthesia is unique because it is (1) obtained from surrogates (ie, parents) rather than from the patient and (2) sought after parents have authorized the surgical intervention. There are limited data on how pediatric anesthesia informed and consent discussions are conducted. The purpose of this study was to characterize the content of preanesthesia informed consent discussions and assess their impact on parent recall and understanding. METHODS: We conducted a cross-sectional observational study at a tertiary pediatric hospital. We audio-recorded and transcribed preanesthesia consent discussions between pediatric anesthesia providers and parents of children undergoing elective surgery. Parents were recruited on the day of surgery and completed a survey postdiscussion to assess their recall and perceived understanding. We used directed content analysis to identify 7 informed consent elements: (i) description of the plan; mention of (ii) alternatives, (iii) risks, and (iv) benefits; (v) discussion of uncertainties; (vi) assessment of comprehension; and (vii) solicitation of a decision. We used multivariable logistic regression to explore the association between discussions that included 3 informed consent elements (description of plan, mention of risks, and mention of benefits) and parent recall and understanding of these elements. RESULTS: We analyzed 97 discussions involving 41 different anesthesia providers. The element most frequently included in preanesthesia discussions was a description of the plan (100%); the least frequently included was decision solicitation (18%). Seventy-one percent of discussions included ≥5 informed consent elements and 70% included a description of the plan, mention of risks, and mention of benefits. Parental recall of these 3 informed consent elements was associated with their inclusion in the preanesthesia discussion (75% vs 34%), and more parents understood all 3 elements if they had reported (vs not reported) recall of all 3 elements (97% vs 53%). CONCLUSION: Most pediatric preanesthesia discussions include ≥5 informed consent elements and describe the plan, mention risks, and mention benefits. Inclusion of these latter 3 consent elements was associated with parental recall of these elements but not understanding.

Clinician-parent discussions about influenza vaccination of children and their association with vaccine acceptance.

OBJECTIVE: To examine how clinicians communicate with parents about influenza vaccination and the effect of these communication behaviors on parental vaccine decision-making. STUDY DESIGN: We performed a secondary analysis of data obtained from a cross-sectional observational study in which health supervision visits between pediatric clinicians and English-speaking parents of young children were videotaped. Eligible visits occurred during the 2011-2012 and 2013-2014 influenza seasons, included children ≥6months, and contained an influenza vaccine discussion. A coding scheme of 10 communication behaviors was developed and applied to each visit. Associations between clinician communication behaviors and parental verbal vaccine acceptance and parental visit experience were examined using bivariate analysis and generalized linear mixed models. RESULTS: Fifty visits involving 17 clinicians from 8 practices were included in analysis. The proportion of parents who accepted influenza vaccine was higher when clinicians initiated influenza vaccine recommendations using presumptive rather than participatory formats (94% vs. 28%, p<0.001; adjusted odds ratio 48.2, 95% CI 3.5-670.5). Parental acceptance was also higher if clinicians pursued (vs. did not pursue) original recommendations when parents voiced initial resistance (80% vs. 13%, p<0.05) or made recommendations for influenza vaccine concurrent with (vs. separate from) recommendations for other vaccines due at the visit (83% vs. 33%, p<0.01). Parental visit experience did not differ significantly by clinician communication behaviors. CONCLUSION: Presumptive initiation of influenza vaccine recommendations, pursuit in the face of resistance, and concurrent vaccine recommendations appear to increase parental acceptance of influenza vaccine without negatively affecting visit experience.