Implications for practice and research

• Decision aids can help inform parents about vaccine decisions for their children, which is critical in an age of vaccine hesitancy and refusal.

• Web-based decision aids may be a low-cost or free means of helping parents to understand the measles, mumps, and rubella (MMR) vaccination, supplementing information they receive from healthcare providers.

Context

It is not uncommon for parents to express vaccine hesitancy, request modified childhood vaccination schedules, refuse vaccines for their children or file for non-medical exemptions from school-required vaccinations.1 Moreover, outbreaks of vaccine-preventable illnesses are becoming more common.2 Healthcare providers strive to give parents all the necessary information. However, with short visit times and multiple issues to address, it may be challenging to educate parents about childhood vaccines. Additionally, providers and commonly-used leaflets tend to emphasise benefits of vaccines without addressing hesitant parents’ concerns. Some investigators have developed online decision aids to inform parents and help them to think through paediatric health issues, including vaccination. The authors conducted an economic analysis of an adapted online MMR vaccine decision aid targeted towards parents.

Findings

MMR vaccine uptake was the highest among the online decision aid arm, followed by the usual care only arm. Least effective was the leaflet arm. Cost models demonstrated that the adapted, online decision aid was the most likely of the three arms to be cost-effective from a healthcare payer and societal perspective. The models also suggested that the leaflet arm not only resulted in decreased MMR vaccine uptake, but that it also is most likely to be the costliest from a societal (eg, healthcare payer and parental) perspective.

Commentary

The authors present an economic analysis of a paediatric decision aid, an area lacking in the literature. They conclude that an adapted, online decision aid concerning the MMR vaccination not only has a positive impact on vaccine uptake, but is also likely to be cost-effective. Further, they cautioned that, based on their data, use of leaflets may undermine efforts to ensure MMR vaccine uptake.

As the authors mention in the study's limitations, their model made several assumptions, including that an existing online decision aid would be free or have negligible cost. Costs were also lower because parents who used the decision aid seemed less inclined to contact their doctors. However, the sample size of the DECIDA randomised controlled trial was relatively small.

Published vaccine leaflets and, to some extent, healthcare providers, argue the benefits of vaccines and the dangers of forgoing them. This study suggests it may be more effective to foster patient-centeredness and engagement by directing them towards online decision aids that help educate them, inform their decisions, and decrease decisional conflict. In the context of childhood immunisations specifically, online decision aids recommended by healthcare providers may be seen as trustworthy and reputable, thus potentially being weighted more heavily in decision-making. Such decision aids can supplement the usual care delivered by a healthcare provider. If the decision aid is an existing one that is freely accessible, costs to the healthcare provider should be minimal. As noted by the authors, in an age of texting and emailing, links to decision aids can be easily disseminated to patients and many decision aids are freely available online.4 However, if providers wish to modify an existing decision aid or create a new one, they should be aware that incurred costs (eg, development and web hosting) may become substantial.