Dr. Douglas Opel, a general pediatrician and researcher at Seattle Children’s, addresses questions about his recently published study on communication with parents about vaccinations.
Thank you to Dr. Wendy Sue Swanson, a pediatrician at The Everett Clinic in Mill Creek, a member of Children’s medical staff and author of the Seattle Mama Doc blog, for submitting these questions.
Q. What communication approach did you find was most effective for parents in general and for vaccine-hesitant parents in particular?
A. One particularly interesting communication practice was how the child’s provider started the vaccine discussion with the parent during well-child visits. Three-quarters of the providers in our sample used a presumptive format, which conveys the assumption that the parent will accept the recommended vaccines (e.g., “Well, we have to do some shots.”). The remaining providers used the opposite approach – a participatory format – in which parents are given more decision-making latitude (e.g., “What do you want to do about shots?”).
We found differences in outcomes depending on which initiation format was used. Parents were more likely to express initial verbal resistance to one or more vaccinations when providers used a participatory format compared to when providers used the presumptive format.
They were also more likely to refuse one or more recommended vaccines by the visit’s end when the provider began the vaccine discussion with a participatory format as compared to a presumptive format. This was true even after controlling for a parent’s vaccine-hesitancy status.
Another communication practice of interest was what providers did after a parent voiced initial resistance to vaccines during the vaccine discussion. When providers pursued a parent’s refusal to try to convince them to reconsider (e.g., “If he was my child, I would definitely go ahead.”), about half of parents who were initially resistant changed their mind. Among vaccine-hesitant parents, 27% changed their mind when the provider pursued the topic.
Q. Do you have any tips about communicating with vaccine-hesitant families?
- Don’t be afraid to be presumptive, especially when you are talking with parents about vaccines for the first time. Start the vaccine discussion by telling parents what vaccines their child is due to receive. The large majority of parents have no issues with vaccines, so it’s OK to presume that the parent you are seeing will be one of the majority. You can even be presumptive and still give the parents an opportunity to express their own preference, such as, “Today, Johnny gets his MMR and varicella. Sound OK?”
- If you prefer a participatory approach to start the vaccine discussion, commit to pursuing any refusals, concerns or questions. Even parents who seem to have a strong opinion might only need slight encouragement or reassurance to change their mind. Vaccine hesitancy appears to be a modifiable behavior.
Q. Does national data suggest we’re making progress getting children the vaccinations they need? Are families less hesitant today than they were five years ago?
A. In general, vaccination rates are very good and remain steady. One concerning trend, however, is the number of parents who opt out of school requirements for nonmedical reasons, which is a sort of surrogate metric of vaccine hesitancy. Nationally, nonmedical exemptions increased almost every year from 2006 to 2011.1 In Washington, however, we have seen a decline in exemptions since the new law went into effect in 2011.
Q. You published a study in 2011 about pediatricians’ attitudes toward alternative vaccine schedules. For example, most pediatricians are more comfortable waiting on Hep B vaccination than PCV. When we need to compromise, it seems like alternative schedules are our only choice. Do you have any updates since you published that study?
A. Alternative schedules are increasingly common in today’s practice, and certainly present a dilemma. There is no evidence for anything but the recommended schedule, so it is hard for providers to agree to them given our goal to protect the child from disease.
However, if you have thoroughly explored a parent’s reasons for wanting to delay or refuse and have been unable to convince them otherwise, I’d argue that alternative schedules that at least partially immunize the child are probably better than the alternative of requesting that the parent take their child elsewhere for pediatric care. If you have to prioritize, you would want to pick vaccines that cover diseases that are in active circulation, have severe sequelae or are highly contagious.
Currently, the consensus nationally is to follow a research agenda that promotes the continued testing of the safety and efficacy of the recommended schedule rather than putting resources toward a new agenda that seeks to test the safety and efficacy of alternative schedules. I imagine that might change if increasing numbers of parents continue to use alternative schedules.
- Omer SB, Richards JL, Ward M, Bednarczyk RA. Vaccination Policies and Rates of Exemption from Immunization, 2005–2011. New Engl J Med 2012;367:1170-1171.