How to advise vaccine-hesitant parents

Physicians in the Lower Mainland and on the southern end of Vancouver Island immunize a large proportion of BC infants and children, and physicians in other parts of the province are key informers about immunization even if the immunization service is given by a public health nurse. All providers struggle with how best to approach difficult conversations with parents who are unsure about or opposed to vaccination. Such parents span a spectrum of vaccine hesitancy. They may have questions that can be answered easily, or they may be firmly entrenched in their antivaccination views. This article provides a brief synopsis of guidelines for having these conversations.

Physicians who have experience talking with vaccine-hesitant parents have developed a number of resources,[1-3] and these resources have been summarized in Immunize BC’s Immunization Communication Tool for Immunizers, available online or in print from your local health unit.[4] Many studies have shown that the strongest factor in parents’ decision to vaccinate their child is a clear recommendation from a trusted health care provider.

The majority of children are immunized, and emerging evidence indicates that starting the conversation with a positive statement that assumes the child will be immunized (an opt-in approach) is more successful. This simplifies a complex decision, which appears scientific on the face of it but which includes a strong emotional component for the parents (fear of hurting the child). Listen to the parents’ perspectives and concerns in a nonjudgmental manner. The encounter is more effective when the information is tailored to the parents’ needs, so ask about their specific worries—what have they read, seen, heard, or been told? Try to explore what is motivating their decision. Is there an antivaccine family member who they don’t want to displease? While many parents will cite concerns about vaccine safety, they will decide to vaccinate their child if they perceive a benefit to the child. For parents, a benefit to the child is a more important consideration than a benefit to society as a whole.[5]

Most concerns about vaccine safety can be addressed by discussing the typical side effects associated with the vaccine, including local redness, pain and swelling, or fever, and how to manage these at home. Point out that serious adverse events are very rare and that you have taken the appropriate precautions to identify contraindications to avoid preventable serious adverse events.

Research indicates that vague responses do not engender confidence. Illustration through stories about cases of vaccine-preventable disease is more helpful than providing statistics, but it is important to define numerically what you mean by terms such as common or rare, which may be used to describe the risk of disease and its complications, and frequency of an adverse event. Try not to oversell immunization. Inform yourself through the excellent resources available in the journal Pediatrics[6-9] and other sources from the Centers for Disease Control and Prevention and the Canadian Paediatric Society.[10,11]

A different approach is required for parents who are firmly opposed to vaccinating their child; literature suggests that providing standard vaccine information and refuting misconceptions may further entrench such parents in their position. In such cases it may be prudent to state your recommendation and leave the door open for future conversations.[12]

Finally, advise parents about the guidelines and systematic reviews available in support of measures to reduce infants’ and children’s experience of pain associated with injectable vaccines.[13,14] 
—Monika Naus, MD, FRCPC
Medical Director, Immunization Programs and Vaccine Preventable Diseases Service

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This article is the opinion of the BC Centre for Disease Control and has not been peer reviewed by the BCMJ Editorial Board.

References

1.    Halperin S. How to manage parents unsure about immunization. Can J CME 2000;12:62-75.
2.    MacDonald NE, Finlay JC; Canadian Paediatric Society, Infectious Diseases and Immunization Committee. Working with vaccine-hesitant parents. Paediatr Child Health 2013;18:265-267.
3.    Healy CM, Pickering LK. How to communicate with vaccine-hesitant parents. Pediatrics 2011;127(Supp l):S127-S133.
4.    Derban A, Harper J, Jiwa S, et al. ImmunizeBC. Immunization communication tool for immunizers, 2013. Accessed 29 July 2015. www.immunizebc.ca/healthcare-professionals/immunization-communication.
5.    Hendrix KS, Finnell SME, Zimet GD, et al. Vaccine message framing and parents’ intent to immunize their infants for MMR. Pediatrics 2014;134:e675-e683.
6.    Offit PA, Moser CA. The problem with Dr Bob’s alternative vaccine schedule. Pediatrics 2009;123:e164-e169.
7.    Offit PA, Jew RK. Addressing parents’ concerns: Do vaccines contain harmful preservatives, adjuvants, additives, or residuals? Pediatrics 2003;112:1394-1397.
8.    Offit PA, Hackett CJ. Addressing parents’ concerns: Do vaccines cause allergic or autoimmune diseases? Pediatrics 2003;111:653-659.
9.    Offit PA, Quarles J, Gerber MA, et al. Addressing parents’ concerns: Do multiple vaccines overwhelm or weaken the infant’s immune system? Pediatrics 2002;109:124-129.
10.    Centers for Disease Control and Prevention. Provider resources for vaccine conversations with parents. Accessed 29 July 2015. www.cdc.gov/vaccines/hcp/patient-ed/conversations/index.html.
11.    DL Moore (ed). Your child’s best shot: A parent’s guide to vaccination. 4th ed. Ottawa, ON: Canadian Paediatric Society; 2015. 370 p.
12.    Nyhan B, Reifler J, Richey S, et al. Effective messages in vaccine promotion: A randomized trial. Pediatrics 2014;133:e835-e842.
13.    Halpert C, Meier S, Naus M. Reducing immunization injection pain in infants. BCMJ 2015;57:189.
14.    Shah V, Taddio A, McMurtry CM, et al. Pharmacological and combined interventions to reduce vaccine injection pain in children and adults: Systematic review and meta-analysis. Clin J Pain 2015. E-pub ahead of print.