Working with vaccine-hesitant parents: An update

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Background

Vaccine hesitancy – which refers to delays in accepting or refusing vaccines, despite the availability of vaccination services – is a growing health concern worldwide^[1][2] and is increasingly recognized as a barrier to immunization program success. Health care providers play a crucial role in fostering vaccine acceptance among vaccine-hesitant parents^[3][4]. While most Canadian parents (an estimated >90%^[5]) ensure their children receive all routine immunizations, health care providers will also encounter parents who are either hesitant to accept – or refuse outright – certain or all recommended vaccines. One Ontario study revealed that while exemptions to measles-containing vaccines have remained stable over the previous decade (at <2.5%) and the rate of medical exemptions has declined, the rate of nonmedical exemptions for school children rose over the same period^[6]. This practice point updates an earlier version^[7] and offers evidence-based guidance for clinicians on how to engage effectively with vaccine-hesitant parents and form a decision-making partnership in the best interest of children (see checklist).

1. Understand the key role that sound vaccine advice from a health care provider can play in parental decision-making

With all vaccines, the strength of the recommendation from the physician or nurse can influence a parent's decision to vaccinate their child or be vaccinated themselves^[4][8][9]. Parents who have received vaccine information from a physician have far fewer vaccine concerns than parents who rely on friends, family or the Internet^[10][11]. Accurate information and reassurance provided by a health care provider are frequently cited by parents who planned to delay or refuse a vaccine as the main reasons they changed their minds^[4][12]. A cross-Canada survey done in 2015 showed that most parents trust advice from health care workers, public health and other credible sources^[13]. It is worth noting that when health care providers are not up-to-date with their own immunizations, their patients are also less likely to be up-to-date^[14]. Since the pandemic, there has been heightened awareness that COVID-19 vaccine hesitancy among some health care workers negatively impacted both peers and patients. Ensuring that health care providers know about vaccine benefits – and about the risks of vaccine-preventable diseases – and are able to convey both to parents in an unbiased way, is critical.

Some physicians become frustrated when dealing with parents who refuse to immunize their children. While a minority of such parents (<2% estimate in Ontario^[6]) never change their minds, many more become more accepting of vaccines when their concerns are listened to and addressed appropriately. Developing trust in the immunization program and with a health care provider are key elements in supporting vaccine acceptance^[15]. It is critical that providers are not only knowledgeable (i.e. competent), but also patient, caring and compassionate, especially when interacting with parents who are marginalized racially, culturally, or economically. Multiple visits for discussions around vaccine issues may be needed and progress may be slow, but is worth the effort. The best possible outcomes are that parents better understand the risks of vaccine-preventable disease, that safeguards are in place to ensure vaccines are safe and effective, and their children are fully immunized. Every health encounter is an opportunity to discuss vaccination. For some parents, the question "What would it take for you to accept vaccines for your child?" may open up discussions that could, over time, prove fruitful.

When faced with parents who refuse to immunize their children, some physicians consider dismissing the family from their practice as an option. However, in the Canadian context there are complex legal, ethical and public health issues in play^[16]. Withholding care from a child is unlikely to prompt parents to agree to immunization, cannot be considered to be in the child's best interests and may violate a health care professional's ethical responsibilities.

2. Use presumptive and motivational interviewing techniques to understand a parent's specific vaccine concerns

How vaccination is presented to the parent matters. A presumptive approach (e.g., "Sarah needs to be immunized today"), is far more likely to result in vaccine acceptance than is a participatory approach (e.g., "What do you want to do about Sarah's shots?")^[17]. However, even with a presumptive approach, parental concerns must be addressed in a non-judgemental, non-confrontational manner.

Motivational interviewing techniques, which are client-centred, semi-directive and intended to change behaviour, can be very helpful ^[18][19]. Use of open-ended questions, affirming what has been heard, listening reflectively and then summarizing are all key components. What specific concerns does the parent have? Never assume what the vaccine concern(s) maybe and do not overestimate concerns^[20]. Above all, listen carefully.

When there are vaccine concerns, acknowledge why a parent might believe misinformation about a vaccine, especially when a misunderstanding has occurred. Correct misconceptions, but be careful not to bring spurious vaccine allegations not raised by a parent into the conversation. Providing new reasons for concern, even when unfounded, can lead to the perception that a vaccine is dangerous and encourages hesitancy. When parents have concerns about vaccine safety, emphasizing the robustness of Canada's vaccine safety system may be helpful^[21]. Putting focus squarely on vaccine-preventable disease risks, especially by telling a compelling true story, can help personalize information and make it more relevant for the parent^[22][23]. If you lack personal experience with specific cases, powerful true stories can be found at Immunize Canada to strengthen family-centred counselling.

Addressing health equity may help to guide decision-making among younger parents, who already enjoy better health and freedom from many infectious diseases thanks to routine childhood vaccines. Asking the question, "Don't you want your child to have the same health advantages you had?" may help open discussions. Consider also this statement: "Immunizations provide so many health benefits. Let's give these benefits to your child".

3. Use simple, clear language to present evidence of disease risks and vaccine benefits, fairly and accurately

Parents may believe that their child is at lesser risk for infectious disease because of good health, privileged socioeconomic status or protection by breastfeeding. However, the evidence is strong that healthy non-immunized children are often the populations most affected during outbreaks because of their wider social networks compared with many adults. For example, the measles outbreak in the Lanaudière region of Quebec in 2015 was not only linked to the Disneyland California outbreak but cut a wide swath across non-immunized children and adults in their home community. This outbreak demonstrated that serious infectious diseases, with potentially dangerous health consequences, are only one airplane ride away from most Canadian communities.

As a health care provider, be especially aware of the language you use. Choose clear vocabulary to describe disease or vaccine risks. For example, explain what you mean by 'common', 'rare' or 'extremely rare'. Use the same denominator when comparing disease or vaccine risks. Parents likely will not understand single event probability. If the child develops encephalitis as a complication of measles, it's "full" encephalitis not "1/1000" encephalitis even though the latter is the risk for this complication. It is often helpful to emphasize that many diseases can have serious complications, like measles, that are not always correctable, even with the very best medical care like measles encephalitis and the damage it does to the brain.

Framing your message is key^[24][25]. 'Framing' can mean choosing one non-equivalent outcome over another (i.e., positive gains versus negative losses). For example, saying "a vaccine is 99% safe" is more effective than saying "only get 1% of people experience side effects". Similarly, saying "If you decide not to be immunized against human papillomavirus (HPV), you increase your chances of getting HPV and getting cervical cancer", is more effective than saying, "If you decide to get the HPV vaccine, you decrease your chances of getting HPV and cancer and giving HPV to your partners". Avoid academic jargon that can be misinterpreted or misunderstood^[26]. The Canadian Paediatric Society's definitive book, Your Child's Best Shot^[27] and Immunize B.C.'s Immunization communication tool are excellent resources for answering parents' questions. They both use simple, clear language and avoid the all-too-common language pitfalls of academic medicine.

Some practitioners find web-based decision aides helpful for educating parents about specific vaccine benefits and risks^[28]. However, some websites require parents to spend time reading documents online, which is not always appealing or practical. To be practical, a decision aide needs to also fit the Canadian context (e.g., aides developed in the United Kingdom may not always agree with provincial/territorial health policies).

4. Reduce barriers to vaccine administration

Address pain head on: The fear of immunization pain and distress felt by many parents is often overlooked by health care providers. An updated, evidence-based clinical practice guideline to reduce immunization-related pain in young children, older children and teens, developed by HELPinKids&Adults (https://caringforkids.cps.ca/uploads/handout_images/painreduction_under3_e.pdf and https://caringforkids.cps.ca/uploads/handout_images/painreduction_kidsandteens_e.pdf) and approved by the Canadian Paediatric Society^[29], provides effective strategies for parents, health care professionals and patients to use to ease the vaccine experience.

5. Community protection (herd immunity) does not guarantee personal protection

Some vaccine-hesitant parents rely on "herd immunity" to protect their child from vaccine-preventable diseases^[13]. These parents may not always know that herd protection for some diseases, such as tetanus does not exist. Be sure to remind such parents that the tetanus-causing spore lives in dust and soil and can never be eliminated. Deciding to defer tetanus immunization until an accident happens can be especially tragic, because many Canadian cases have occurred in people who sustained a trivial injury, such as a scrape^[30]. The term herd immunity can also be off-putting for some parents as they see it implying their child is a cow or goat. Community protection is a better term as it does not imply everyone in the population is immune^[31].

Taking a "wait and see" attitude to any vaccine puts children at risk of harm, especially when disease outbreaks occur. Also, full protection against many diseases cannot be achieved with just one dose of vaccine. Even when vaccines are efficacious with a single dose, they may act too slowly to reliably protect a child who is vaccinated during an outbreak. At least two to three weeks are usually needed to achieve protective antibody levels.

Always remind parents that a decision not to immunize can have consequences for others. A healthy but unvaccinated child can spread a vaccine-preventable disease to family members and beyond, and especially to high-risk individuals. Potentially serious consequences include infecting an infant sibling with pertussis, a pregnant friend with rubella or a grandparent with influenza or pneumococcal pneumonia.

Describing these risks can influence parental decision-making, especially when they are made relevant to a family's particular situation. Be sure to emphasize the importance of altruism – of protecting each other – within the family and wider community. Stories from parents of children who cannot be immunized due to an underlying condition (e.g., immunodeficiency or cancer) are particularly powerful and can help drive messaging home.

Finally, parents who refuse to immunize their children must be informed not only of associated risks but also of the responsibilities they assume in making this decision. The Canadian Paediatric Society's Caring for Kids website has a document for parents that outlines these risks and responsibilities.

To sum up, dealing with vaccine-hesitant parents takes knowledge and skill. A parent's specific concerns must be understood and a trusting relationship developed. Effective communication requires being able to present evidence that is easy to hear and understand, while demonstrating care and compassion for both child and family. It is important to educate parents by answering their questions clearly and calmly, using language they can understand and (if appropriate) evidence-based research to support your statements. Telling stories about vaccine-preventable disease cases in Canada can help.

Taking the time to convey information well can make the difference between a child being immunized or not. Most importantly, do not dismiss vaccine refusers from your practice but rather, work with them to ensure their children receive quality care. Because immunization is one of the most important preventive health measures in existence – responsible for saving literally millions of lives each year – addressing the concerns of vaccine-hesitant parents is an important priority for every health care professional.

Checklist: Physician approaches to vaccine hesitancy Aim not to ever dismiss a parent or child from practice: Every office encounter is an opportunity to revisit and discuss vaccines Set aside extra time to counsel vaccine-hesitant parents. Try not to 'rush' these interactions Identify specific parent concerns and make a list Be non-judgemental and non-confrontational Start with assuming that a child will be vaccinated as needed (i.e., be presumptive) Be ready to discuss both the benefits of vaccines and the risks of vaccine-preventable diseases and vaccines Validate parental concerns and correct misconceptions, fairly and accurately Be careful to frame data clearly and positively. For example, it is better to say "99% safe" rather than "1% risk" of side effects Keep up-to-date resources on hand to help answer questions. When discussing the risks of vaccine-preventable diseases: Tell compelling stories. Use Immunize Canada as a resource. Ask parents who have been spared from serious childhood diseases, such as polio, because of vaccines whether they want the same protection for their child? Remind parents that some complications from disease are serious and untreatable, even today. Address pain management for vaccines based on guidance found here: (https://www.cmaj.ca/content/187/13/975) or on the CPS Caring for Kids website. When addressing community protection: Explain that current levels of vaccine uptake are not high enough to prevent all vaccine-preventable disease outbreaks. Point out that waiting for an outbreak before vaccinating a child is often too late to ensure protection. Stress personal responsibility: that choosing not to vaccinate puts vulnerable people at risk. Refer to this CPS Caring for Kids information for how best to do this.

Addendum

The original 2018 guideline predated the COVID pandemic, which added hugely to understanding of, and insights into, the barriers facing some vaccine-hesitant parents that influence immunization-related intentions and behaviours. Recently published guidance from the American Academy of Pediatrics (AAP) “highlighted the need for health care professionals (HCPs) to utilize an ‘attitudes, intentions, and behaviour’ framework to understand and counter vaccine hesitancy and improve vaccine uptake.Working with vaccine-hesitant parents involves addressing and, whenever possible, reducing or eliminating barriers to access and uptake. Organizing after-hour or “pop-up” clinics that are both convenient and culturally sensitive can help overcome common challenges related to access, language and culture, and improve vaccination rates.

Three new recommendations follow:

• Be sensitive to the lived realities of racialized and Indigenous parents, and their resultant distrust of the health care system. Whenever possible, engage an Indigenous or racialized health care team to help with vaccine counselling.
• Directly address issues of pain and anxiety when parents raise them on behalf of children.
• Whenever possible, facilitate or refer parents to special or after-hours vaccine clinics.

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Acknowledgements

This practice point was reviewed by the Community Paediatrics and Acute Care Committees of the Canadian Paediatric Society. It was also reviewed by representatives of the College of Family Physicians of Canada.

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CPS INFECTIOUS DISEASES AND IMMUNIZATION COMMITTEE (2018)

Members: Natalie A Bridger MD; Shalini Desai MD; Ruth Grimes MD (Board Representative); Timothy Mailman MD; Joan L Robinson MD (Chair); Otto G Vanderkooi MD
Liaisons: Upton D Allen MBBS, Canadian Pediatric AIDS Research Group; Tobey Audcent MD, Committee to Advise on Tropical Medicine and Travel (CATMAT), Public Health Agency of Canada; Carrie Byington MD, Committee on Infectious Diseases, American Academy of Pediatrics; Fahamie Koudra MD, College of Family Physicians of Canada; Rhonda Kropp BScN MPH, Public Health Agency of Canada; Nicole Le Saux MD, Immunization Monitoring Program, ACTive (IMPACT); Jane McDonald MD, Association of Medical Microbiology and Infectious Disease Canada; Dorothy L Moore MD, National Advisory Committee on Immunization (NACI)
Consultant: Noni E MacDonald MD

Principal authors: Noni E MacDonald MD, Shalini Desai MD, Betty Gerstein MD

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References

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Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.