Immunization is a public health success story. Although vaccination against infectious disease is one of the most effective preventive health strategies, approximately 1 in 10 parents refuses vaccines when visiting their pediatric healthcare provider.1,2 Whether or not to immunize children may be a difficult choice for some parents because vaccine-preventable diseases have become less common and parents have little familiarity with the devastating effects of vaccine-preventable illnesses. Thus, the benefits of immunization may seem less important than the potential adverse effects.1
Barriers to vaccination include cost, inadequate access to healthcare, religious or moral beliefs, and misinformation.3 The most neoteric stance of someone who refuses immunization is the disproven theory that vaccines cause autism.4-6 The clinicians' challenge is to approach misinformed parents with rational, scientific dialogue.
Characteristics of Refusal
Parents receive health information from many sources. Some of these are reliable and some are not. Conversations about vaccines on television and on the Internet often give equal or greater weight to nonscientific data than to the rigorous scientific studies that confirm vaccines are safe and effective.1,4-6 Parents seek out advice from these alternative sources in an effort to find answers to their common reasons for refusal (safety, perception of disease and pain). One in 5 parents may explore alternative immunization scheduling for multiple reasons.7
Characteristics of parents who refuse or delay vaccines have been identified in general terms. These parents tend to be older white women who have graduated from college and have an annual household income greater than $75,000. They may prefer the risk of errors of omission over errors of commission.
The parent who refuses or questions vaccinations generally fits into a one of five vaccine hesitancy categories:1,8
the uninformed but educated, who seek information to counter an anti-vaccination message
the misinformed, who are not fully aware of the benefits of childhood vaccination
the well-read and open-minded, who have explored both sides of the vaccination issue and want to discuss this information to put it in an appropriate context
the convinced, who are strongly vaccine hesitant but want to demonstrate their willingness to listen to the other side of the argument
the committed and missionary, who want to convince the provider to agree with their arguments against vaccination.
The first three groups are likely to be amenable to provider dialogue and information, whereas the latter two groups are unlikely to ever change their position no matter how much factual information about vaccination is provided or how much dialogue takes place.1,8
Provider characteristics can also create barriers to immunizations. If the primary care provider does not offer immunizations, availability becomes a problem.9 If the provider requires a well-child check-up before administering vaccines, this may become a financial barrier to vaccination.9 The child may be seen for another medical problem but not offered immunizations secondary to time constraints or provider workload.9 Clinic hours may be impractical for parents and thus they utilize convenient care clinics or the emergency department as a substitute for primary care, creating more missed opportunities to immunize.9
Providers (and parents) may have trouble keeping up with the frequently changing immunization schedule and its complexity. Physician assistant and nurse practitioner education programs may not adequately stress the importance of immunizations, resulting in a lack of knowledge about dealing with vaccine refusal, dosing schedules and indications for and contraindications to immunizations.10 Expanding numbers of vaccines recommended for routine use and newly added categories of high-risk groups meriting the offering of immunizations (e.g., human papillomavirus vaccine administration schedules for 11- and 12-year-olds) make it difficult for of providers to stay current with immunization schedules and guidelines.10
Additionally, some providers perceive the provision of immunizations as a potential liability and therefore don't provide them in the office setting. Instead, they suggest parents immunize their children through the local public health department. This creates another appointment requirement and possible missed work for the parent.10
Logistical barriers faced by providers may include costs of immunizations, difficulties in vaccine storage or availability, and lack of access to patients' prior immunization records.11 Uninsured and Medicaid insured children may qualify to receive vaccines through the Vaccines for Children (VFC) program, but VFC does not provide funding to reimburse providers for the cost of administering those vaccines.3,8,11 Fragmentation of patient care makes it more likely that providers will not have complete immunization records for patients currently in their care.11 This can lead to over-immunization and incomplete immunization. Vaccine registries (i.e., computer databases within a specific geographic area) can provide access to the records of enrolled patients. However, surveys demonstrate that only 3% of providers nationwide use immunization registries to help monitor their patients' immunization status.9
Clinicians must be able to communicate with patients and guardians who either have concerns about vaccines or refuse to vaccinate their child. In addition, clinicians should have a variety of avenues to convey the importance of vaccination and disease prevention. Providers who administer immunizations must have the ability to develop approaches that will increase adherence rates, educate patients and families about the benefits and risks of immunization, and continually educate themselves about current vaccine recommendations (including contraindications).
Over the past 2 decades, advances in vaccination have resulted in safe and effective preventive health measures that have saved children from death or serious sequelae from vaccine- preventable diseases. This is one of medicine's greatest triumphs. Our expanding knowledge also gives rise to periodic updated immunization recommendations. Physician assistants and nurse practitioners must be aware of the latest developments in order to incorporate up-to-date recommendations in clinical practice. Thus, to improve immunization rates among our patient population and decrease vaccine-preventable disease, and to decrease the burden that these preventable conditions place on our communities, clinicians need to improve in the following areas:
1. The ability to effectively communicate with patients and guardians about immunization safety concerns and the importance of disease prevention.
2. Confidence to educate and persuade parents who refuse to vaccinate their children.
3. Utilizing every opportunity, including sick visits, to immunize children.
4. Thorough understanding of immunization schedules, dosing and side effects.
5. Knowledge and utilization of national and regional immunization registries.
Ben Taylor is a physician assistant at Doctors Care of Aiken in Aiken, S.C. He is the immediate past president of the Association of Family Practice Physician Assistants. He has completed a disclosure statement and reports no relationships related to this article.
The Association of Family Practice Physician Assistants (AFPPA) is a growing organization of physician assistants and nurse practitioners who practice in primary care settings such as family practice, internal medicine, emergency medicine, pediatrics, women's health and occupational medicine. The AFPPA offers peer-to-peer continuing medical education in small group settings at conferences held throughout the year. Learn more at www.afppa.org.
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