By implementing a comprehensive vaccine decision support system directed at clinicians and families, we integrated multiple elements (clinician-focused reminders, education, and feedback as well as family-focused reminders and education) into a coherent intervention informed by EMR data.
Despite concerns that sending reminders about a potentially sensitive topic like HPV vaccination would generate controversy, the family-focused decision support was acceptable to families of adolescent girls who were due for the HPV vaccine and remembered receiving the call. There were few complaints from parents about the appropriateness of the calls, and responses suggest that the calls had an effect on the decision making process. In fact, multiple parents reported that the calls prompted specific behaviors including seeking out information, discussing the vaccine with others, and giving thought to their decision, even if they had previously procrastinated. These results suggest that, as long as a proper framework is used, family-focused decision support can be used in the context of controversial medical issues such as HPV vaccination.
We found that half of the parents surveyed remembered receiving the reminder phone call. The finding that many parents did not remember the call is not surprising, as other studies of reminder/recall interventions have found that calls may be ignored by families or not reach them due to wrong numbers or other factors.36, 37
However, nearly a third of parents who remembered the call actually reported changed behavior as a result. These results suggest that phone reminders might be an effective way of reaching families with decision support.
An additional component of the intervention in this study was the direction of families to a specific, evidence-based website. Though we hypothesized that families would visit the website listed in the reminder phone call, none of the subjects surveyed visited the site. This may be due to difficulty understanding or remembering the link to the website. It is noteworthy that parents did report that they were prompted by the calls to seek out information elsewhere--from other websites, family, friends or their child’s clinician. These results suggest that family-focused decision support might lead to more informed decision-making on the part of parents, though reminder phone calls may not be the best method of directing parents to specific educational content on the internet. Other vehicles for decision support, including text message or email reminders, may better direct parents to specific web-based educational content. However, in order to implement decision support using these methods on a large scale, information including email addresses, text message capable phone numbers and permission to send health-related messages must be documented as a part of routine practice, a workflow not yet adopted in many settings. Additionally, new patient portal systems have the potential to deliver decision support and educational material to patients.38–40
A web-based portal might deliver vaccine reminders to patients by email and include links or direct access to patient education resources tailored to specific families.
Our results suggest that aspects of the family-focused decision support intervention might work differently in parents with varied demographic characteristics. For example, non-white parents were more likely than white parents to report that the call prompted them to seek information about the HPV vaccine. Previous research has shown that African American and Hispanic caregivers in some areas may have less knowledge regarding the HPV vaccine than white caregivers;41, 42
it is possible that interventions designed to promote information-seeking might be particularly effective in this group.
We also found that college-educated parents were more likely than those with less education to report that the call affected the likelihood that they would vaccinate their child. It is possible that parents with less education preferred a greater level of clinician input. Prior research has found that caregivers with higher educational levels were more likely to report intention to seek out information about the HPV vaccine online;41
this may indicate greater confidence in their ability to seek health information on their own. Further research is needed to evaluate the impact of the decision support intervention among different subgroups of families.
This study had several limitations. First, the survey selection process was not random, but rather sought to obtain an adequate quota of complete responses. Our goal was to assess the acceptability of the phone contact process overall and among subgroups of families. Second, our survey instrument may not have captured all factors impacting the acceptability of the intervention to parents. We asked an open-ended question, but did not probe specific barriers. Additionally, we conducted the study in one health care system located in a single region of the country; as such, the study population likely does not represent the entire U.S. population. However, our results do show that the intervention was acceptable to parents of varying demographic characteristics and of younger as well as older adolescents.
This study used the EMR as the foundation for a multifaceted intervention to improve adolescent vaccine delivery in ambulatory settings. This approach is acceptable to families and might foster information-seeking, discussion with family and peers, and decision-making.