Preserving relationships with antivaccine parents

As pediatric vaccination concerns persist among some segments of the population, physicians might increasingly find themselves confronted by parents who do not wish to have their children vaccinated. This interaction can create tension between physicians and parents, and could threaten the integrity of ongoing therapeutic relationships.^1,2 In some cases, this has led to the termination of the relationship, either because physicians refuse to see children whose parents refuse vaccines or because parents will not deal with doctors who insist on vaccination.³

The perspective of physicians is understandable in these interactions. Physicians have a responsibility to provide care, so a decision by parents not to allow their children to be vaccinated could be viewed as unacceptable and might even be perceived by physicians to be abusive. Nevertheless, physicians must make every effort not to let this perception result in a scenario where they are no longer providing care for those children. To do so would be problematic from several perspectives. First, the decision not to be vaccinated is not being made by the children; however, the breakdown of the therapeutic relationship would effectively punish the children for the parents’ decision. Second, it assumes that vaccination is the only important intervention physicians provide to children and undervalues the remainder of the health care physicians deliver. Third, these children are at the most risk of developing vaccine-preventable diseases; therefore, physicians want to ensure that they see them on a regular basis, both for the children’s benefit and for public health purposes. Finally, the best hope of ensuring that these children are vaccinated is to have the opportunity to address the vaccination question in the future by keeping the parents and children in the practice.

Physicians, however, face many difficulties unique to talking with parents about their children.^4,5 To assist physicians with managing this difficult issue, we present 5 suggestions adapted from social psychological research (Table 1). They are intended to help physicians maintain positive relationships with antivaccine parents to ensure that their children continue to receive routine medical care—whether the parents eventually choose to vaccinate or not. The suggestions are centred on establishing trust, which has been frequently identified as a key component in influencing parents’ vaccination decisions.^1,2

Table 1.

Strategies for physicians to maintain positive relationships with antivaccine parents

PSYCHOLOGICAL PRINCIPLE	PHYSICIAN STRATEGY
Naïve realism
People assume that their understanding of the world is correct.	Ensure that you understand what parents are saying when they raise the issue of vaccinations. Are they decidedly antivaccine, or are they seeking reassurance? Tailor your approach accordingly.
Reactance
When faced with information or arguments that threaten a deeply held belief, people will often strengthen that belief.	When parents raise doubts about vaccines, don’t react in an aggressive or dramatic fashion. This will often cause parents to solidify their opinions in the opposite direction.
Precedence of negative information
When forming impressions or making decisions, people often give greater weight to negative information than to positive information.	Don’t let your discussions about vaccination escalate into an argument that could taint your future interactions with the parents.
Attributions
People generate explanations for the motives behind others’ behaviour. These attributions are often consistent with prior impressions of the individual’s character.	Maintain a positive relationship with all families. Parents will explain your behaviour in ways that are consistent with their prior experiences with you. If their prior interactions with you were positive, they will attribute your actions around vaccination to more positive motives.
Superordinate goals
The motives or ideals that 2 people or groups have in common. Belief in superordinate goals is a component of trust and can be used as a conflict-resolution technique.	Make sure that parents understand that you are sincerely concerned for their children’s health and welfare. Let this serve as a reminder that this ideal is something you and the parents have in common. It positions you and the parents on the same side, as opposed to being adversaries.

Naïve realism

When parents raise the issue of vaccine safety or indicate that they are unsure about whether or not they will have their child vaccinated, physicians must be certain that they understand exactly what the parents’ concerns are. For example, a question such as “Isn’t that vaccine dangerous?” can be interpreted in a couple of ways. It can mean “I am certain that it’s dangerous and I’ve made up my mind”; or it could mean “Is it dangerous or not? I need your advice.” Parents who believe the first statement will likely not be persuaded to vaccinate; people who hold a belief so strongly often become even more firmly convinced of their correctness when faced with persuasion attempts.⁶ Parents to whom the second statement applies, however, might be receptive to a physician’s information in favour of vaccination. Determining which category better suits the parents will allow physicians to tailor their subsequent approach. This process of mindfully questioning one’s first impression is not a natural inclination to most people because individuals tend to assume that their view of the world is correct, an approach known as naïve realism.⁷

Reactance

Whether confronted with parents who are uncertain about vaccination or those who are determined to avoid it, physicians must not react in an aggressive fashion. An outright attack on people’s deeply held beliefs will often cause them to strengthen those beliefs in a response known as reactance.⁸ A vigorous condemnation can, therefore, do more harm than good by further polarizing parents’ thinking.⁹ This could particularly alienate those who have considered vaccination at one point.¹⁰ Medical professionals must be especially wary, because there is evidence that overt persuasion attempts from figures of higher social status can be even more likely to elicit reactance than persuasion from peers or those of lower status.⁷ Therefore, when facing parents who are vehemently opposed to vaccination, physicians should calmly voice their concerns without making inflammatory statements, such as calling into question parents’ concern for their children.

Precedence of negative information

Previous research indicates that vaccination can be a “wedge” topic that drives parents and medical professionals apart, and discussions about it can become quite heated.^1–3,11 An argument with a physician is the kind of intensely negative experience that can taint the parents’ subsequent interactions with the doctor. Psychological research shows that negative events often have a stronger and more lasting effect on people’s impressions than do positive events,¹² so that even one argument could have a damaging effect on the parents’ opinions of the physician. It is, therefore, the responsibility of the physician to ensure that the discussion does not evolve into an argument. Instead, physicians are better advised to state their perspective and, if the discussion seems to be growing confrontational, to change the topic. This is particularly important for those parents who are determined not to vaccinate, because the likelihood of persuading them is low. One way for physicians to avoid a confrontation without completely closing the door on the vaccination issue is to conclude the discussion by promising to raise the issue again after a specific period of time—1 year, perhaps. A recent survey of pediatricians and family practitioners indicates that this approach might already be in use.¹¹

Attributions

Even when physicians and parents strongly disagree on the issue of vaccinations, it is important to make efforts to maintain a positive relationship. It is not surprising that the best way to do this is to foster a cordial and trusting relationship with all families right from the start, before the issue of vaccinations has even been approached. Maintaining positive relationships has several important functions. People are more likely to be influenced by those they like than those they dislike.¹³ Furthermore, a long-term relationship is often needed to build trust.¹⁴ In the case of parents who are uncertain about vaccination, they might be more likely to agree to vaccinate if they have a good impression of the physician than they would if they did not. For parents who are fervently antivaccine, they might be more likely to tolerate listening to a trusted and well-liked physician’s information about vaccination than to that of a disliked physician.

Maintaining a positive relationship is particularly important because parents’ prior experience with the doctor will determine how they interpret the physician’s behaviour around a contentious issue like vaccination. These interpretations are known as attributions. When people witness another individual’s behaviour, they will often make attributions about the personality traits or situational influences that caused the behaviour.¹⁵ If parents’ interactions with the physician have all been uneventful but they suddenly find that they disagree on an issue such as vaccination, parents are likely to interpret the physician’s insistence on vaccinating in a way that is consistent with their prior opinion of the doctor. If that prior opinion was positive, parents will likely explain the physician’s behaviour in more favourable terms (eg, “My physician is just trying to do her job and is concerned about my child”) than if previous interactions were more negative (eg, “My physician does not value my opinions”).

Superordinate goals

Superordinate goals refer to those motives and ideals that 2 groups or individuals have in common. For the vaccination conflict, parents and physicians can agree that children’s best interests represent their common ground. The belief in superordinate goals is an important component of trust: expecting that the trusted other individual will act as a result of altruistic (as opposed to selfish) motives.¹⁴ In this case, it would translate to parents believing that physicians have sincere care and concern for their children.

The focus on common ground is also a proven conflict-resolution technique, in that it helps to prevent an adversarial mentality by putting both parties of a conflict on the same side.¹⁶ With this final recommendation in mind, it follows that physicians’ refusal to treat children whose parents refuse vaccination is especially destructive. It tells parents they were right not to trust doctors, as they are obviously not concerned about their children’s health. Superordinate goals are another component best established at the start of the relationship. Parents’ prior impression of the physician should include the physician’s genuine concern about their children’s health.

Conclusion

Even though it is a contentious issue, disagreements over childhood vaccinations need not create permanent rifts between parents and physicians. Physicians can take steps to ensure that discussions about vaccination are respectful, even if the parents are determined not to vaccinate their children. We hope that these 5 suggestions from social psychology will supply physicians with some tools to help these interactions proceed smoothly.