Abstract
This survey study assesses US pediatrician practices and office policies in response to parents who either refuse primary vaccinations or request to spread out individual vaccines in the primary series.
In January 2019, the World Health Organization declared vaccine hesitancy one of the top 10 threats to global health.1 Some US pediatricians dismiss children from their practice whose parents refuse vaccination.2 However, little is known about the current prevalence of this practice.
Methods
We conducted a survey from April to July 2019 among US pediatricians using a physician survey network. Physicians were recruited to fill sampling quotas representative of American Academy of Pediatrics membership with respect to region, practice location, and practice setting and asked to complete 2 to 4 surveys each year.3
The survey assessed pediatricians’ current practices, experiences, and office policies regarding dismissal of families who refuse or ask to “spread out” either vaccines in the primary series or any vaccines using a series of 4-point Likert scales (never, rarely, sometimes, often/always) and yes-or-no questions. The survey was pilot tested in national samples of pediatricians. The survey was administered via mail or internet (Vovici) using Dillman’s tailored approach.
We compared respondents with nonrespondents using t test and χ2 analyses. We conducted a multivariable analysis with the dependent variable of having an office policy to dismiss families for vaccine refusal of 1 or more vaccines in the primary vaccine series. Independent variables included practice characteristics, presence of a state philosophical exemption, and state’s degree of difficulty in obtaining an exemption (easy vs medium/difficult).4 We used log-binomial regression to obtain risk ratios and 95% CIs. P values were 2-sided and P < .05 was considered significant. Analyses were performed using SAS software, version 9.4 (SAS Institute Inc).
The human subjects review board at the University of Colorado approved this study as exempt.
Results
The response rate was 68% (303/448). The mean age of respondents was 53 years, 36% were male, and 79% were in private practice. Respondents were not significantly different than nonrespondents with respect to age, sex, practice setting, census location, and size of practice.
Office policies for dismissal because of vaccine refusal or “spreading out” were more commonly reported than individual physician dismissal behaviors (Table 1). For example, 51% of pediatricians reported that their office had a policy to dismiss families if they refused vaccines in the primary series, while 37% of physicians reported often/always doing this themselves. Physicians more frequently dismissed families for refusing (37%) than for spreading out (6%) vaccines in the primary series, and a similar pattern was seen for office policies (51% for refusal vs 28% for spreading out).
Table 1. Individual Physician Practices and Office Policies for Addressing Vaccine Refusal (N = 303).
| Variable | No. (%)a | ||||||
|---|---|---|---|---|---|---|---|
| Physician | Office policy | ||||||
| Often/always | Sometimes | Rarely | Never | Yes | No | Don’t know | |
| Require parents to sign a form if they refuse vaccination | 168 (57) | 47 (16) | 23 (8) | 56 (19) | 184 (66) | 87 (31) | 9 (3) |
| Dismiss families from your practice if they refuse vaccines in the primary series for their child | 109 (37) | 28 (9) | 17 (6) | 141 (48) | 141 (51) | 135 (49) | 2 (1) |
| Not accept new patients who do not agree to give their child all vaccines according to the recommended vaccination schedule | 100 (34) | 23 (8) | 22 (7) | 150 (51) | 129 (46) | 148 (52) | 5 (2) |
| Not accept new patients who do not agree to give their child some vaccines according to the recommended vaccination schedule | 84 (29) | 42 (14) | 26 (9) | 141 (48) | 124 (44) | 150 (54) | 6 (2) |
| Agree to “spread out” vaccines in the primary series | 58 (20) | 123 (42) | 80 (27) | 33 (11) | 102 (37) | 168 (60) | 8 (3) |
| Not accept new patients who insist on spreading out vaccines | 32 (11) | 31 (11) | 40 (14) | 192 (65) | 84 (30) | 191 (68) | 6 (2) |
| Dismiss new patients who insist on spreading out vaccines | 22 (8) | 20 (7) | 41 (14) | 207 (71) | 77 (28) | 191 (69) | 7 (3) |
| Dismiss families from your practice if they choose to “spread out” vaccines in the primary series for their child | 18 (6) | 21 (7) | 46 (16) | 209 (71) | 78 (28) | 196 (70) | 5 (2) |
| Refer patients to other practitioners within your practice who will allow them to deviate from the recommended vaccination schedule | 2 (1) | 4 (1) | 18 (6) | 267 (92) | 64 (23) | 204 (73) | 10 (4) |
| Refer patients to specific practitioners outside your practice who will allow them to deviate from the recommended vaccination schedule | 9 (3) | 21 (7) | 22 (7) | 242 (82) | 55 (20) | 212 (77) | 9 (3) |
| Parents sign a contract that their children must be up to date by a certain age, but the parents may spread out the vaccines | 14 (5) | 20 (7) | 17 (6) | 243 (83) | 52 (19) | 213 (76) | 14 (5) |
Some percentages may not add up to 100% because of rounding. Missing data for physician practices ranged from 2% to 4% and for office policies from 6% to 9%.
Among physicians who reported they ever (rarely, sometimes, or often/always) dismiss families for refusing vaccines in the primary series (n = 154), 18% reported that those parents often/always change their mind and agree to vaccination when presented with the policy (48% sometimes, 29% rarely, and 5% never).
Offices in community/hospital-based clinic/health maintenance organization settings were less likely than private practices to have a dismissal policy (risk ratio, 0.28 [95% CI, 0.14-0.49]) as were practices in the Midwest (risk ratio, 0.66 [95% CI, 0.47-0.91]; referent to the South) (Table 2).
Table 2. Bivariable and Multivariable Analyses of Pediatric Offices With a Policy to Dismiss Families for Refusing Vaccines (N = 276)a.
| Variable | Office dismissal, No. (%)b | Bivariable P value | Multivariable risk ratio (95% CI) | Multivariable P value | |
|---|---|---|---|---|---|
| No (n = 135) | Yes (n = 141) | ||||
| Practice settingc | |||||
| Private practice | 86 (64) | 132 (94) | <.001 | 1 [Reference] | <.001 |
| Community or hospital based/HMO | 49 (36) | 9 (6) | 0.28 (0.14-0.49) | ||
| Census location | |||||
| Rural/suburban non–inner city | 71 (53) | 64 (45) | .23 | 1 [Reference] | .05 |
| Urban inner city | 64 (47) | 77 (55) | 1.22 (1.00-1.51) | ||
| Region of country | |||||
| South | 37 (27) | 57 (40) | <.001 | 1 [Reference] | .03 |
| Midwest | 36 (27) | 25 (18) | 0.66 (0.47-0.91) | ||
| Northeast | 23 (17) | 41 (29) | 0.95 (0.77-1.19) | ||
| West | 39 (29) | 18 (13) | 0.70 (0.45-1.02) | ||
| State allows philosophical exemption | |||||
| Yes | 70 (52) | 42 (30) | <.001 | 1 [Reference] | .12 |
| No | 65 (48) | 99 (70) | 1.23 (0.95-1.65) | ||
| Difficulty of getting exemption | |||||
| Difficult | 67 (50) | 67 (48) | .89 | 1 [Reference] | .30 |
| Medium | 46 (34) | 52 (37) | 1.20 (0.95-1.47) | ||
| Easy | 22 (16) | 22 (16) | 1.10 (0.80-1.40) | ||
Abbreviation: HMO, health maintenance organization.
Dependent variable is a response of yes to the question “Does your office have a policy to dismiss families from your practice if they refuse vaccines in the primary series for their child?”
Some percentages may not add up to 100% because of rounding. Practice characteristics included in the model were practice setting, census location, and region of the country. A generalized Hosmer-Lemeshow test found no evidence of lack of fit of the model.
Number of practitioners per practice and practice setting were sufficiently correlated that both could not be included in model (median for community/hospital based/HMO is 9 vs 5 for private practice; Wilcoxon P < .001). In bivariable analysis, the number of practitioners as a continuous variable was not significantly associated with having a dismissal policy (Wilcoxon P = .60).
Discussion
This study among US pediatricians showed that the practice of dismissing families who refuse vaccines for their children was common, with half of pediatricians reporting their office has a dismissal policy, although fewer personally dismiss patients. A survey administered in 20122 using the same methodology as in the present study found that 21% of pediatricians reported they often/always dismissed families for refusing vaccines2 compared with 37% in the present study.
Some argue that having a dismissal policy for vaccination leads otherwise resistant parents to agree to vaccinate.5 This study showed some pediatricians perceive this to be true, with more than half of pediatricians with a dismissal policy reporting parents at least sometimes agreeing after learning of the policy.
Because vaccine refusal is common,6 the high prevalence of dismissal for families who refuse has important implications. Future work should explore the effect this practice has on vaccination rates, whether it results in parents changing their mind about vaccination, and whether it decreases access to medical care or erodes trust in clinicians.
Limitations of this study include that respondents may have differed from nonrespondents in unmeasured ways and that findings are based on reported rather than observed practices.
Section Editor: Jody W. Zylke, MD, Deputy Editor.
References
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