We, as pediatricians, have the incredible opportunity and privilege of providing life-savingmedicine to children in the form of immunizations. Overall vaccination coverage remains high nationally, but the percentage of young children who have received no vaccines has increased over the past several years. This fact has recently gained significant attention both in the medical community and in the political arena. Of course, many factors may be contributing to lack of immunization in some communities, including lack of access to healthcare or health insurance, but the discussion about causality is most often focused on vaccine hesitancy among parents. As physicians who are interacting daily with parents who may be hesitant about vaccines (or simply parents who have questions about immunizations in general), pediatricians must be prepared to participate in discussions about vaccines in a productive and meaningful way.  

Certainly, there is need for advocacy regarding immunizations at a population level. However, there is also an immense opportunity for advocacy at the individual patient level. A 2013 survey conducted by the AAP showed that 87% of pediatricians have encountered parents who refuse a vaccine. Studies have shown that howproviders initiate and pursue vaccine recommendations with parents is associated with parental vaccine acceptance. In other words, it is not simply our responsibility as pediatricians to provide the recommendation to immunize – it is our responsibility to engage parents in discussion about vaccines, answer their questions, address their concerns, and help them feel confident in choosing to immunize their children. 

In order to participate successfully in these discussions with families, we must stock our proverbial toolkits with a plethora of skills and strategies. We all have our own unique communication style, but incorporating some key (and proven) tools into our everyday practice is essential to our effort to increase vaccination uptake while maintaining partnerships with families.

• Using a presumptive approach– We are taught in medical school and residency to use open-ended questions when obtaining a history. When discussing vaccines with parents, using the opposite approach has actually been shown to be more effective. It is important to remember that most parents areplanning to vaccinate, and we can introduce the topic with that assumption. Using a presumptive approach means using language such as, “Johnny is due for 3 shots today,” as opposed to “What do you think about Johnny’s shots today?” One study showed that, among all parents, more parents chose to vaccinate their children when providers used a presumptive approach.

• Debunking myths – Families may have questions about some of the commonly publicized concerns about vaccines, and we must take time to appropriately address them. The goal is to increase families’ familiarity with the facts while avoiding making the misinformation more familiar. Minimizing the influence of misinformation is a difficult and complex challenge, but one which pediatricians can be well-equipped to handle with practice. In a resource called “The Debunking Handbook” by J. Cook and S. Lewandowsky, the authors state that there are 3 key elements to debunking: 
• Focus on the facts rather than the myth.
• If the myth is mentioned, it should be preceded by the warning that the information is false.
• The debunking should include an alternative explanation that addresses the important qualities of the misinformation in question. 

Using this debunking strategy has been demonstrated to be effective. This video from the CDC is a concrete example of a pediatrician answering difficult questions from parents using some of these debunking techniques: https://www.cdc.gov/cdctv/diseaseandconditions/vaccination/get-picture-childhood-immunization.html

• Motivational interviewing– Studies have shown that only providing facts and information to vaccine hesitant parents is an ineffective method to increase parents’ intention to vaccinate. Motivational interviewing (MI) is a patient-centered approach focusing on enhancing a person’s ownmotivation for change. It employs the techniques of using open-ended questions to explore concerns (if any are encountered after using a presumptive approach), providing affirmations and reflective listening, and summarizing what the person has expressed to you. One study showed that MI training for providers was effective at increasing uptake of the HPV vaccine. Here is an example of an MI-style interview (borrowed from an MI training module through Denver Metro Alliance for HPV Prevention):

Parent: “I think Mary is way too young for an HPV vaccine. I mean, she’s only 11 years old. I think you doctors are pushing this too soon. Someday, she may consider getting vaccinated, but not now.” 

Provider: “It’s really hard for you to believe that the HPV vaccine is right for Mary when she’s so young. That just doesn’t make any sense at all.” 

Parent: “Exactly!”

Provider: “Well I can certainly understand why you would feel that way (affirmation). May I share the reasoning behind vaccinating early (autonomy, supportive education) – then you can tell me what you think?” (collaboration)

Becoming comfortable with MI can take time. There is an abundance of training videos and modules for providers online, but the best way to practice is in daily conversations with our patients and families. Using MI when we encounter vaccine hesitancy allows parents to feel heard and respected, encourages them to share their honest concerns and thoughts without pressure or judgement, and may lead them to form new conclusions about vaccines. 

We cannot depend on any one of these tools in isolation and must be prepared to call on them in tandem as questions and concerns from parents arise. Remember that our responsibility is to build trust with families and to be able to have honest and thoughtful conversations about decisions that affect their child’s health. Encountering vaccine hesitancy can seem overwhelming, frustrating, and discouraging at times. However, we must realize that success comes in many forms and that the conversations will be ongoing. Stocking our toolkits with strategies like these is a simple way to take advantage of the precious time we spend with families and the immense opportunity to advocate for every one of our patients. 

Gaylan Dascanio, MD

Resources:

Opel, D. J., MD, MPH. (2015). The Influence of Provider Communication Behaviors on Parental Vaccine Acceptance and Visit Experience. The American Journal of Public Health, 105(10), 1998-2004.

Cook, J., Lewandowsky, S. (2011), The Debunking Handbook. St. Lucia, Australia: University of Queensland. November 5. ISBN 978-0-646-56812-6. [http://sks.to/debunk] 

Reno JE et al. Improving Provider Communication about HPV Vaccines for Vaccine-Hesitant Parents Through the Use of Motivational Interviewing. J Health Commun. 2018;23(4):313-320. 

https://www.cdc.gov/vaccines/hcp/conversations/index.html