How You Start the Conversation Matters

Abstract

Immunization rates are one of the many measures of quality care that are of interest to physicians. Immunization rates for children younger than 3 years of age in Minnesota have held steady between 80% and 90%. One reason they have not increased is because of emerging hesitancy among some parents to vaccinate their children. This article describes what research has taught us about working with vaccine-hesitant parents and how starting a conversation in a way that presumes parents will vaccinate may improve the odds of children getting immunized.

Immunization coverage rates for 19- to 35-month-old children in Minnesota are between 80% to 90%, depending on the vaccine. Those rates have been stagnant since 1996. Moreover, the rate of completion of the combined series of vaccines for Minnesota children in this age group sits steady at 66.2% (±7.6).¹ Although the overwhelming majority of Minnesota parents are vaccinating their children, vaccine hesitancy has likely contributed to our inability to attain the Healthy People 2020 goal of 80% vaccination coverage for the childhood series.² Evidence suggests that 13% of parents of children ages 6 months to 6 years in the United States request an alternative immunization schedule for their child.³

Some parents who are vaccine-hesitant may simply need more information or reassurance before accepting all vaccines; others may delay or accept some vaccines but not others. About 1% of parents refuse all vaccines. Research has shown that most vaccine-hesitant parents perceive their child’s physician as having an important influence on their decisions when it comes to vaccinating their children. In a 2003-2004 study of parents, the largest portion of those who initially planned to delay or not vaccinate their child but eventually did cited talking to their child’s physician as their reason for changing their minds.⁴

Talking to a Parent

Conversations in which parents refuse recommended vaccines can be difficult for both physicians and parents. When having the vaccine conversation, experts advise that physicians and other providers use plain language, remain nonjudgmental, listen to all the parents’ concerns, and show compassion and understanding.⁵ The CDC and other organizations have developed tools to help guide clinicians when they’re talking to vaccine-hesitant parents (see box).

The Centers for Disease Control and Prevention (CDC) offers resources to help physicians and other providers have vaccine conversations with parents. They are available on the CDC website www.cdc.gov/vaccines/hcp/patient-ed/conversations/index.html.

In addition, it is important to recognize the barriers to having an effective conversation with a vaccine-hesitant parent. Lack of time is commonly cited. Given the competing demands physicians and other health care providers face, they may not have enough time to adequately address a parent’s concerns regarding vaccines during well-child visits. Another barrier is the physician’s ability to balance his or her obligation to promote the health of the child with the parent’s autonomy. Finally, there has been a glaring lack of evidence regarding communication strategies that are effective in changing parents’ behaviors when it comes to vaccinating their children.

This is changing. New evidence suggests that the way clinicians start the vaccine conversation matters. For instance, one study demonstrated that when providers initiated the conversation in a way that presumed the parents would be vaccinating their child (eg, saying “It’s time to start all those vaccines. We’re going to give two live vaccines today: MMR and chickenpox”), rather than in a way that didn’t make this assumption and instead simply invited parents to be involved in the decision (eg, saying “So what are we going to do about vaccines today?”), fewer parents expressed resistance to vaccinating their children (26% vs. 83%, respectively).⁶ This association remained statistically significant even after controlling for parental hesitancy status, parent and child demographics, and visit characteristics.

Why might a presumptive format for initiating vaccine recommendations be preferable to one that is more participatory? One reason may be because of how we as humans make decisions. When making what we perceive to be a complicated decision, we tend to have a status quo bias. Many parents—hesitant or not—perceive the vaccination decision to be a complicated one. When it is presented to them that their child will receive vaccines (ie, by using the presumptive format), parents may inherently be inclined not to challenge the recommendation, as they see having a child vaccinated as what most people do. A study of how parents make vaccination decisions showed “exposure to social norms”—with vaccination being the expected norm—was a major influence on their decisions.⁷

We are also beginning to understand the importance of physicians and other health care providers making their recommendations even if the parent is hesitant. Among parents who initially resisted a provider’s vaccine recommendation, 47% changed their mind when their provider continued to discuss their recommendation.⁶ When having a discussion about your recommendation, you should explore the parent’s concerns and provide them with additional information that can assuage those concerns. Doing so can make a difference.

Improving the Odds

How you initiate and discuss your vaccine recommendation can be important in determining whether a parent chooses to vaccinate, even if the parent may be hesitant. Remember that as a physician, you have influence with parents when it comes to vaccine decisions and that you can harness this influence by soliciting parents’ concerns and taking the time to address them. Don’t be afraid to start the vaccine conversation with your recommendations and pursue them if the parent resists. Taking this approach while still being respectful, empathetic and understanding can improve the chance that a parent will accept your recommendations. MM