Strategies for talking to parents about vaccines for children

Strongly recommend and use presumptive format

When introducing the childhood vaccine schedule, healthcare providers should always default to strongly recommending the shots, according to the American Academy of Pediatrics (AAP).

"There is higher vaccine receipt among children whose parents receive a very strong clinician vaccine recommendation than those who do not," AAP says. "The ability to confidently provide such a strong recommendation is based on decades of broad national and international pediatric health care experience, data collection, and rigorous, well-designed studies of vaccine safety, efficacy, and effectiveness."

Relatedly, AAP recommends using a "presumptive format" when initiating discussions about vaccinations in kids. This means clinicians use a closed-ended statement, like "your child is due for several vaccinations today," AAP says.

"Clinician use of a presumptive format is associated with increased vaccine uptake, even among parents with negative vaccine attitudes," the organization added, emphasizing that the strategy is low-cost and low-burden for providers.

A presumptive format works because it creates an opt-out format for getting a child vaccinated. When individuals are faced with a decision, they tend to go with the default option. Thus, by presenting vaccination as opt-out, the odds are that more people will proceed with the default option of getting the child vaccinated.

Furthermore, a presumptive format positions vaccination as the norm, which in some cases can reach even parents with strongly held vaccine hesitancy.

"Utilizing defaults in communication with parents merits careful consideration," AAP cautioned. "Defaults ought not be used indiscriminately and are most justifiable where there is a high degree of certainty that an intervention is of low risk and high benefit."

Still, healthcare providers might face pushback from parents after using a presumptive format. Clinicians need to come equipped with a number of communication strategies, ranging from motivational interviewing to empathic patient education, to address vaccine hesitancy.

Motivational interviewing

Healthcare providers faced with a parent expressing vaccine hesitancy should utilize motivational interviewing, a technique often used in chronic disease management, to build trust and get to the heart of parental concerns. Using open-ended questions, clinicians can better understand what's driving vaccine-hesitancy and determine where to steer the conversation next.

AAP says that clinicians should begin with affirmation to make the parent feel supported, appreciated and understood. For example, the provider might tell the parent they are a good parent and that their concerns underscore their commitment to their child's safety. Scripting might sound like, "if you thought the vaccine was safe, you would not hesitate because you want what's best for your child," for instance.

Next comes reflection, or the mirroring back of how the parent seems to be feeling. This can deepen rapport, encourage partnership and continue to affirm that the parent is heard by the provider. AAP says this is particularly useful when a provider works with a parent with deep seeded vaccine hesitancy.

Clinicians might say, "you're frightened by what you've seen online" or "it sounds like you are worried about the possibility that the MMR vaccine might cause autism."

Then comes a turning point in the conversation where a provider might begin sharing more scientific information about the vaccine in question. However, providers should ask permission to share first, as this will ensure parents will be in a less defensive position, AAP explains. Asking permission to share can also help parents feel more open to receiving the information.

Clinicians might say something like, "may I share some information based on what you've shared with me?" or "I have a different view, may I share with you?"

Finally, healthcare professionals should support the parent's autonomy and reaffirm their sense of control during the conversation, ideally making parents feel more at ease. A clinician can say things like "my position notwithstanding, this is a decision only you can make" or "only you can choose what is best for your child."

Debunk vaccine myths without judgement

It is likely that providers speaking with vaccine-hesitant parents will hear parents voice numerous myths. For example, a provider discussing the MMR vaccine might hear the debunked falsehood that the shots are linked with autism.

AAP suggests providers use what it calls "truth sandwich messaging" that helps chip away at the medical misinformation. The correct information should be seen as the bread, while the misinformation is somewhat sandwiched in between.

For example, a provider might use the following scripted provided by AAP:

"Parents and doctors agree kids deserve to be safe and healthy. Anyone holding up one study or statistic to undermine the advice of nearly all pediatricians is painting a misleading picture for their own gain. Instead, let's support healthy communities by vaccinating children to help their bodies recognize and resist disease."

Importantly, healthcare providers should go to lengths to ensure they do not shame their patients for believing medical misinformation.

Medical falsehoods are rampant across the internet and social media, so it is easy for patients to encounter this type of information. Healthcare providers should acknowledge that misinformation is difficult to avoid and that it preys on parents' fears and best wishes for their child. Then, they should use plain and direct language to explain the truth.

Pursuing adherence in the face of hesitancy

When a parent expresses vaccine hesitancy or suggests they might refuse a vaccine, AAP says it's okay for providers to also push back. This practice is called pursuing adherence and has shown to move the needle on vaccine refusal.

"Pursuing adherence refers to responding immediately to a parent’s initial reluctance to the vaccines for which their child is due with a reiteration of the importance of the recommended vaccines for the child, such as 'He really needs these shots,'" AAP explains.

"In several observational studies, parental verbal acceptance of vaccines for their child was significantly higher when clinicians pursued their vaccine recommendations (versus acquiesced) after initial parent reluctance."

Bundle vaccine discussions

Pediatric healthcare providers might consider bundling their vaccine conversations and having them all at once. In other words, chatting about every shot necessary in the near-term during one office visit.

According to AAP, this strategy is effective for some shots more than others. For example, data has shown that discussing the flu vaccine when also talking about other steps in the childhood vaccine schedule can increase uptake of the flu shot.

This approach can be effective partially because clinicians can tell parents that it minimizes the pain often associated with getting a shot, which can be of significant concern for parents.

Draw on personal experience

At the end of the day, patients and their parental caregivers trust their doctors. When providers give their own personal testimonies and experiences about vaccines, it can be influential.

Providers might share that they and their family have received the vaccinations in question. Particularly, clinicians should stress their own belief in the safety and efficacy of a vaccine. They might say something like, "I felt comfortable giving this vaccine to my own child," for example.

They might also share personal experiences with vaccine-preventable diseases, such as explaining what it was like treating a child who was very sick with measles.

Look outside the pediatric clinic into the community

Although the patient-provider relationship is a key part of discussion pediatric vaccines, AAP suggests that providers should also look outside their own clinics.

Community-based approaches, like getting the backing of religious groups or other culturally relevant bodies, can be helpful. School-based vaccination programs can also introduce vaccination as a social norm, which increases uptake.

Considering SDOH and vaccine hesitancy

According to pharmaceutical manufacturer Merck, the social determinants of health (SDOH) are intrinsically linked with vaccine hesitancy.

Indeed, there are steep disparities in vaccine hesitancy across numerous demographics. Black, Hispanic and other race kids are more likely to have parents who are vaccine hesitant. Similarly, kids with a mom with less than a college degree are more likely to have vaccine-hesitant parents, as are kids with parents living below the poverty level.

These factors could affect trust and confidence in the medical system, Merck indicated. For example, folks from traditionally marginalized backgrounds might have more distrust. Relatedly, folks with lower educational attainment and lower health literacy might not trust in vaccines or see the urgent need for them.

Moreover, parents facing numerous SDOH are less likely to have easy access to vaccines. They might not be able to schedule appointments that align with their work schedules, face transportation barriers or perceive affordability issues.

As healthcare providers consider their communication strategies for discussing pediatric vaccines, they should consider the SDOH that kids and their parents might currently experience. This can help providers tailor their conversations. Likewise, considering a patient's cultural background can help personalize conversations.

Next steps when parents refuse to vaccinate

Despite providers' best efforts, a parent still might choose not to vaccinate their child. Indeed, some recent studies have shown that even with best provider efforts, strategies like presumptive format and motivational interviewing don't sway the most vaccine-resistant.

Clinicians should not give up on these parents, CDC advises. Instead, they should try a more long-term approach to addressing vaccine-hesitancy among parents.

Continuing the conversation about vaccines during the next visit is key, CDC says. Pediatric offices can completement these efforts with the community-based strategies listed above. Likewise, pediatricians can send families home with educational materials about why and how they can get their child vaccinated.

In the meantime, parents who choose not to vaccine their child need to know how certain vaccine-preventable illnesses present, as their child is liable for contracting them, says the CDC. Providers should offer patient education on this matter. For example, explaining what the measles rash looks like and how parents can proceed if they observe it in their children will be helpful.

Similarly, should their child fall ill, parents should be advised to call before bringing their child to a healthcare professional. This will allow the facility to take the necessary precautions for treating a patient who has not been vaccinated, CDC said.

"Explain that when scheduling an office visit for an ill child who has not received vaccines, you will need to take all possible precautions to prevent contact with other patients, especially those too young to be fully vaccinated and those who have weakened immune systems," the agency says on its website.

Finally, CDC said providers might consider having families sign the AAP's Refusal to Vaccinate form.

AAP says the form helps healthcare providers understand a parent's reasoning behind refusing a vaccination. Although it is not a legal document, the form can also help mediate some provider liability. This form is akin to patients signing a form acknowledging they are leaving a healthcare facility against medical advice.

The issue of medical misinformation and spread of vaccine hesitancy is an urgent problem in the U.S., as healthcare and public health professionals continue to observe rising cases of vaccine-preventable illnesses such as measles. By reviewing the best practices for talking to parents about vaccines for their child, providers will be better equipped to educate and address concerns.

Sara Heath has reported news related to patient engagement and health equity since 2015.