Monday morning: a routine visit by a young mother with her small child. A discussion about vaccine safety ensues. After an average visit of between 10 and 19 minutes, and equipped with the latest statistics and several leaflets, the mother leaves to consider her options. Sound familiar? Will she return the following week to get her child started on the recommended vaccine schedule? Will she ask for a delayed schedule? Will she opt out entirely?
A recent paper analyzing the American Academy of Pediatrics (AAP) Surveys highlighted that the number of pediatricians who report parental vaccine refusal rose from 74.5 percent in 2006 to 87 percent in 2013.
The perception that parents thought the vaccinations were unnecessary increased from 63.4 percent to 73.1 percent.
The study also noted that although pediatricians educate parents about vaccinations, they are also dismissing patients more often.
When faced with this situation, what can and should primary care physicians do to support the individual patient, their patient population, and the wider community?
What are parents' concerns about vaccinations?
"Parents have three major reasons, one is that they think that vaccines are no longer needed and the diseases are gone, the second is that they fear that the vaccines are associated with adverse reactions, and third [is that] they think that they should be able to decide what their children should receive and not have to be mandated to receive vaccines for school or other requirements," Dr. Kathryn M. Edwards, the Sarah H. Sell and Cornelius Vanderbilt Chair in Pediatrics at the Department of Pediatrics and Infectious Diseases at Vanderbilt University School of Medicine in Nashville, TN, told Medical News Today.
In an attempt to depolarize the "anti-vaxxers" versus "pro-vaxxers" movements, the acceptable term to use is now "vaccine hesitancy." Within the spectrum of opinion, parental attitudes toward childhood vaccinations can be divided into five categories. These are:
- Unquestioning acceptors (30 to 40 percent): These are advocates for immunizations who feel that vaccines are safe and necessary.
- Cautious acceptors (25 to 35 percent): These are parents who do not necessarily question vaccination but who may not have a full understanding. The cautious acceptors continue to vaccinate their children despite some minor concerns.
- The hesitant (20 to 30 percent): These parents vaccinate their children but have significant concerns, mainly about vaccination risk.
- Late or selective vaccinators (2 to 27 percent): These parents have knowledge about vaccination but still have concerns, sometimes leading to delay or refusal of some vaccines.
- Refusers (less than 2 percent): These parents may have concerns about safety, religious beliefs, or mistrust of the medical system and may ultimately refuse all vaccinations for their children.
This sophisticated stratification of parents into categories improves our understanding of the motivations and reasons that underlie vaccine hesitancy.
The role of the physician: Education and advocacy
Educating vaccine-hesitant parents can be challenging and time-consuming. Physicians may need to anticipate longer visits for these discussions, which may have a knock-on effect on the rest of their daily schedule and, subsequently, lead to reduced job satisfaction. However, there is evidence of the importance of one-on-one interaction between the hesitant parent and their physician in countering hesitancy and safety concerns.
A study in the journal Vaccine in 2014 highlighted the lack of formal training in vaccine safety during most pediatric residency programs in the United States. This survey of members of the Association of Pediatric Program Directors further revealed that over 80 percent wanted formal training for their residents.
So what can physicians do when they find themselves faced with a parent voicing concerns about vaccine safety?
"Physicians need to clearly point out the benefits of the vaccine and tell them that vaccines are the standard of care for children. They have made an enormous difference in the lives of children. No longer do children die of meningitis, measles, and pneumonia since the widespread use of vaccines. Just like pediatricians should stress the use of car seats when children ride in cars, they need to stress the important role of vaccines in assuring child health,"
Kathryn M. Edwards, M.D.
Strategies for approaching the hesitant parent
The AAP Clinical report "Countering Vaccine Hesitancy," published in the journal Pediatrics in 2016, outlines several helpful strategies when approaching the subject of vaccination with a hesitant parent. These include:
- Starting a nonconfrontational dialogue with the parent that simultaneously acknowledges their concerns while emphasizing that vaccines are well researched, safe, effective, and prevent serious diseases. Vaccine misconceptions should be corrected.
- Highlighting to the hesitant parent that alternative vaccine schedules have not been shown to be more effective or safe than the evidence-based vaccine schedule.
- Considering the use of presumptive delivery strategy, a method of presenting vaccination as a requirement to ensure disease prevention. However, not all parents will respond to this approach, and it should therefore be used selectively.
- Taking a personalized approach. This, along with a trusting patient-physician relationship, may also be helpful when other strategies fail with vaccine-hesitant parents. For instance, a physician could share information about the vaccination state of family members and children. Providing personal examples and anecdotes of successes with vaccine-preventable diseases may also be useful in convincing a hesitant parent.
Employing motivational interviewing techniques is another way of approaching a vaccine-hesitant parent, and this involves parents verbalizing their concerns and the physician giving focused answers. Ideally, this interaction should allow the parent and patient to self-reflect and ultimately come to a place of understanding of the benefits of vaccination on their own.
Asking open-ended questions, affirming their efforts, listening reflectively, and assessing the parent's readiness to change their mind, are the key skills used in motivational interviewing, as highlighted in a recent AAP Clinical Report.
If a parent continues to refuse vaccination, perseverance and readdressing the issue at the next visit has been shown to be beneficial. In the 2013 AAP Survey, pediatricians reported that educational interventions with parents who initially refused led to vaccination around 30 percent of the time.
Some physicians dismiss patients who refuse vaccinations from their practice. The AAP recommend taking into account the patient's access to other healthcare providers and following state laws regarding notification, emergency care, and avoiding patient abandonment.
Often, vaccine hesitancy stems from concerns regarding adverse effects. It is, however, also linked to many parents having never been exposed to the diseases that vaccines prevent. Starting at the prenatal visit and continuing through pregnancy and beyond, addressing vaccine hesitancy begins with open dialogue between the parent and physician.
Being prepared to discuss individual concerns, as well as taking the time to explain the evidence and risks involved in deviating from established vaccination schedules, are approaches that have been shown to improve vaccination rates.
If in doubt, reach out and discuss the case with an experienced colleague or mentor. Other resources to consider are:
- The AAP's Immunization section resource
- The Immunization Action Coalition
- The Centers for Disease Control and Prevention (
"You need to listen to the families and address their specific questions. You need to tell them that vaccines are comprehensively studied prior to their use. You need to provide them credible evidence about the vaccines and the diseases that they prevent. The physician is very influential in these interchanges and needs to be knowledgeable about the approach."
Kathryn M. Edwards, M.D.