Clinician-initiated communication recommending influenza vaccination in children influences parental vaccine decision-making, according to a study published in Vaccine.

Annika M. Hofstetter, MD, PhD, MPH, and colleagues from the Department of Pediatrics at the University of Washington and the Seattle Children’s Research Institute conducted a cross-sectional, observational study to characterize clinician communication behaviors and determine whether certain behaviors are associated with parental acceptance of influenza vaccination for their children.


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The study took place in 16 primary care pediatric practices over the course of 2 periods: study period 1 encompassed physician visits from September 2011 to August 2012 (n=113), and study period 2 encompassed physician visits from April 2013 to June 2014 (n=103). English-speaking parents of children aged 1 to 19 months who were receiving care from a participating clinician were eligible to participate in the study.

Participants were screened for vaccination hesitancy using the Parent Attitudes about Childhood Vaccines survey (PACV); vaccine-hesitant parents (VHPs) were defined as those with a total PACV score ≥50 (scale, 0-100). VHPs were oversampled in study period 1 and were the only participants enrolled in study period 2.

All study visits were videotaped; tapes were included in the analysis only if the visit that took place during influenza vaccination season (August-March) involved a child ≤6 months of age and included a discussion about influenza vaccination. Fifty videotaped visits from 17 pediatric clinicians at 8 primary care practices were collected. Parent participants were primarily white, married mothers, aged 30 years or older, with a household income greater than $75,000, who were vaccine hesitant. Data were evaluated on the basis of verbal participant acceptance of the influenza vaccine and postvisit experience survey. The communication formats used by clinicians to recommend influenza vaccination were analyzed and coded into presumptive format and participatory format, which were used 52% and 48% of the time, respectively.

Clinician use of the presumptive format did not differ between visits with non-VHPs and VHPs (67% vs 46% [P =.31]; risk difference, 20%; 95% CI, −13% to 54%), respectively. Forty-four percent of participants immediately accepted a clinician’s initial influenza vaccination recommendation, but acceptance was higher when the clinician used a presumptive format vs a participatory format (72% vs 17%; P <.01). Immediate acceptance under presumptive format was also higher among VHPs (73% vs 13%; P <.01). No significant difference was found between non-VPHs and VHPs (60% vs 38%; P =.29; risk difference, 22%; 95% CI, −15% to 58%). Twenty-five percent of clinicians pursued their recommendations after verbal resistance, although this was more likely with non-VHPs than VHPs (75% vs 13%; P <.05). On clinician pursuit, 60% of parents voiced immediate acceptance.

Overall, 48% of patients accepted influenza vaccination for their child if the clinician used a presumptive vs participatory initiation format (94% vs 28%; P <.001), and more so if the clinician pursued the original recommendation after initial resistance (80% vs 13%; P <.05).

When initiating influenza vaccination with other vaccinations, 47% of participants immediately accepted both vaccines. When there was participant resistance (13 participants), only 23% of clinicians pursued their initial recommendation for both vaccines, 31% pursued for the other vaccines, and 46% did not pursue for either (P <.05). In all, a higher number of participants accepted the influenza vaccine recommendation when made concurrently with other vaccine recommendations (83% vs 33%; P <.01).

“While our previous analyses assessing the association between clinician communication behaviors and parental visit experience in the context of other childhood vaccines similarly found no effect of provider pursuit on parental visit experience, it did show that the proportion of highly rated visit experiences differed by initiation format,” the researchers conclude.

Study Limitations

  • The sample size was small, and was drawn from only 1 geographic reason; results may not be generalizable to other clinicians, practices, or regions.
  • The small sample size reduced study power and the researcher’s ability to perform certain subgroup 
  • Parent and clinician attitudes toward influenza vaccination may have changed between the 2 nonconsecutive study periods.
  • Because of the observational design of the study, the researchers cannot account for unobserved confounding. 


  1. Hofstetter AM, Robinson JD, Lepere K, Cunningham M, Etsekon N, Opel DJ. Clinician-parent discussions about influenza vaccination of children and their association with vaccine acceptance [published online April 6, 2017]. Vaccine. doi:10.1016/j.vaccine.2017.03.077

This article originally appeared on Pulmonology Advisor