Communicating with Patients, Parents, and Caregivers About Vaccination

I realize that some patients resist or decline vaccination. What advice can you offer to encourage them to vaccinate?
Vaccination is clearly a highly successful public health measure, yet an increasing number of persons question whether it is safe or necessary. Vaccine hesitancy, which refers to declining of vaccines, delay of vaccines, or acceptance of vaccines but with reservations about them,1 poses a potential public health problem. High rates of vaccination are needed for control of vaccine-preventable diseases, so vaccine decline or delay by even a small percentage of patients can lead to disease outbreaks. For example, researchers who studied the 2015 measles outbreak linked to a California amusement park found that the vaccination rate among persons exposed to measles during the outbreak was 86% or lower, while the rate needed to establish herd immunity to measles is between 96% and 99%.2

COVID-19 and Vaccinations
The challenge of acceptance and high uptake of vaccines has been clearly demonstrated by the COVID-19 pandemic. COVID-19 vaccines were granted Emergency Use Authorization in late 2020, and since then, vaccines have become available for all persons ages 5 years and older. However, only approximately two-thirds (65.9%) of the US population are optimally vaccinated. Barriers to receiving COVID-19 vaccination include safety and effectiveness concerns, perceived scientific uncertainty, perception that COVID-19 poses a low risk, and low trust in authorities.3 These barriers reflect a growing distrust of science observed in American society over the past several years and are caused, in part, by misinformation about COVID-19 spread through social media and other platforms. Nonetheless, healthcare providers remain parents’ and caregivers’ most trusted source of information on the COVID-19 vaccine for children, and this remains true across race and ethnicity as well as political affiliation.4

In addition, COVID-19 disrupted routine well-child visits for many children over the past 2 years. The Centers for Disease Control and Prevention (CDC) note that public sector vaccine ordering decreased by 14% in 2020-2021 compared to 2019, with measles vaccine ordering down by more than 20%.5 To help clinicians get their patients up to date on recommended vaccines, the CDC has developed online and social media resources outlining the problem and encouraging routine childhood vaccinations.

Importance of Clinician-Patient Communication
Clinician-patient communication is key to overcoming patients’ resistance to vaccination. To the clinician’s advantage, patients often turn to their clinicians as a source of information about vaccines. Studies have shown that parents and caregivers consider clinicians to be the best source for vaccine information, including those who refuse vaccines1,6; furthermore, vaccine-hesitant parents and caregivers cite reassurance and vaccine information from their child’s clinician when explaining why they decided to ultimately accept vaccines.7 To use the clinical encounter to enhance immunization rates, NPs should take a direct approach when recommending vaccines, as discussed below, and be well prepared to discuss recent research and address any concerns patients, parents, or caregivers raise.

Initiating the Vaccine Recommendation
How you initiate and present the vaccine recommendation can have a considerable influence on the patient’s acceptance of vaccination. A practice I have adopted quite successfully is to simply state the following: “Good news. We have a vaccine to prevent the flu. I am going to arrange for you and your child to get this important immunization today.” In other words, do not make this a binary “yes” or “no” issue, just a positive statement. A study by Opel and colleagues7 showed much higher success rates when a direct, nonbinary approach was used to make vaccination recommendations, even with vaccine-hesitant parents and caregivers. Hesitant parents and caregivers were much more likely to resist vaccination if clinicians initiated the recommendation with an open-ended question or either/or phrasing (participatory format; eg, “Are we going to do shots today?”) versus phrasing that presupposed the parent or caregiver would vaccinate (presumptive format; eg, “We have to do some shots to help protect your child.”).7 In this study, 89% of vaccine-hesitant parents and caregivers resisted when a participatory initiation approach was used versus 30% when a presumptive approach was used.

Responding to the Resistant Patient/Parent/Caregiver
The patient, parent, or caregiver can decline, to be sure, or express resistance to vaccines. When this happens, it is important to pursue the recommendation and ascertain their specific concerns. This involves listening to patients/parents/caregivers, acknowledging their concerns in a nonconfrontational manner,8,9 and responding to their concerns constructively. A number of useful resources from the CDC and other groups dedicated to ensuring high vaccination rates are available to assist NPs in this task (Table).

Here are several common concerns raised by vaccine-hesitant patients, parents, or caregivers. Detailed information clinicians can use in responding to these and other vaccine-related questions is contained in the resources listed in the Table.

Are vaccines more dangerous than the diseases they prevent?
Given the great success of vaccination programs in the United States, most people have not observed the effects of the diseases vaccines were developed to prevent (eg, measles, polio, pertussis) and don’t have a clear understanding of the full consequences and complications that can arise from them. You can address this by pointing out that, although the parent/caregiver or patient perhaps has not seen a case of a vaccine-preventable disease firsthand, outbreaks of serious vaccine-preventable diseases still do occur. Regarding the question of safety, it is helpful to describe the preapproval testing and ongoing large-scale surveillance system that are used to ensure the safety of vaccines. The Children’s Hospital of Philadelphia’s Vaccine Education Center provides free Q&A fact sheets in English and Spanish on each vaccine. Written for patients and parents/caregivers, these sheets also include a brief description of the diseases the vaccines prevent and potential complications associated with the diseases.

Do vaccines cause autism?
Concerns about a link between vaccines and autism center on the mumps-measles-rubella (MMR) vaccine and vaccine ingredients, particularly the preservative thimerosal.10 The 1998 study published in The Lancet that raised the notion that the MMR vaccine might cause autism was retracted in 2010, after the authority that registers medical physicians in the United Kingdom, the British General Medical Council, reported that the study’s lead author Dr. Andrew Wakefield had acted irresponsibly and unethically in connection with the research project and its subsequent publication (ie, selecting data to support their case, falsifying data). In addition, subsequent studies have shown that there is no link between receiving vaccines and developing autism, and no links have been found between any vaccine ingredients and autism.11 Although most vaccines no longer contain thimerosal or contain only trace amounts (except for flu vaccines packaged in multidose vials), studies of the preservative have found that it does not cause autism.10

Can too many vaccines in too short a time be harmful?
The number of immunizations a young child receives―up to 27 by age 2 years—can be a concern for parents and caregivers, specifically regarding whether so many vaccines can overwhelm a child’s immune system.12 You can respond that children are exposed to vastly more antigens from their environment on a daily basis than they receive in vaccines, and that their immune systems are well equipped to handle these challenges. Concerns about the timing and schedule of vaccinations can lead parents and caregivers to request alternative schedules that space out the vaccines over a longer period of time. It is important to point out that the timing and spacing of childhood vaccinations is designed to provide protection at the earliest possible time against diseases that infants could contract early in life. Spacing out the vaccines beyond the recommended schedule increases the amount of time children are susceptible to these serious diseases.12

In general, the conversation with a hesitant patient or parent/caregiver should also include the benefits of vaccines and the possible adverse effects. The benefits should be stated in a positive way: as lives saved by vaccination, rather than illnesses or deaths related to lack of vaccination.8 Parents and caregivers should also understand their state’s school entry laws and why they exist (ie, concept of herd immunity). For those who ultimately choose not to vaccinate their children, the conversation should transition to the risks and responsibilities that come with this decision. This includes the need to inform healthcare providers about the child’s vaccination status during all healthcare visits, what to do if an outbreak of a vaccine-preventable disease occurs, and the need to inform the child’s school or childcare facility about his or her vaccination status. Parents and caregivers must also know that unvaccinated students can be prohibited from attending classes during an outbreak of a vaccine-preventable disease at their school or in their community.

Effectively responding to a hesitant patient or parent/caregiver about this important health maintenance intervention in a busy office setting requires knowledge of common concerns, open dialogue and information sharing, and, in some cases, persistence. An encouraging finding from the Opel et al study was that nearly half of the patients who initially resisted vaccination accepted the clinician’s recommendation immediately after providers pursued their original recommendation.7 This finding underscores the importance of persistence as well as the influence of the clinician in vaccine-related decisions. For patients or parents/caregivers who ultimately refuse vaccination, it is important to continue the dialogue at subsequent visits.

Table. Resources for Responding to Vaccine-Hesitant Patients, Parents, and Caregivers

Centers for Disease Control and Prevention
Provider Resources for Vaccine Conversations with Patients: Talking with Parents about Vaccines for Infants

Childhood Vaccination Toolkit for Clinicians
Get Kids Caught Up on Recommended Vaccines for a Safer Return to School.

Childhood Immunization Resources

Immunization Action Coalition
Talking About Vaccines
Need Help Responding to Vaccine-Hesitant Parents?

The Children’s Hospital of Philadelphia
Vaccine- and Vaccine Safety-Related Q&A Sheets

American Academy of Pediatrics

Countering Vaccine Hesitancy

COVID-19 Vaccines in Children and Adolescents

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1. Salmon DA, Dudley MZ, Glanz JM, Omer SB. Vaccine hesitancy: causes, consequences, and a call to action. Am J Prev Med. 2015;49(6 Suppl 4):S391-398.
2. Kaplan K. Vaccine refusal helped fuel Disneyland measles outbreak, study says. LA Times. March 16, 2015. Accessed March 20, 2022.
3. Steffens MS, Bullivant B, Bolsewicz K, King C, Beard F. Factors influencing COVID-19 vaccine acceptance in high income countries prior to vaccine approval and rollout: a narrative review. Int J Public Health. 2022;67:1604221.
4. Kates J, Tolbert J, Rouw A. Update on COVID-19 vaccination of 5-11 year olds in the U.S. Kaiser Family Foundation. January 20, 2022. Accessed February 18, 2022.
5. Centers for Disease Control and Prevention. Help kids’ safe return to school – get caught up on recommended vaccines. Accessed March 20, 2022.
6. Gellin BG, Maibach EW, Marcuse EK. Do parents understand immunizations? A national telephone survey. Pediatrics. 2000;106(5):1097-1102.
7. Opel DJ, Heritage J, Taylor JA, et al. The architecture of provider-parent vaccine discussions at health supervision visits. Pediatrics. 2013;132:1-10.
8. Edwards KM, Hackell JM; Committee on Infectious Diseases, The Committee on Practice and Ambulatory Medicine. Countering vaccine hesitancy. Pediatrics. 2016;138(3):e20162146. Accessed March 20, 2022.
9. CDC. Talking with parents about vaccines for infants. Provider resources for vaccine conversations with parents. April 11, 2018. Accessed March 20, 2022.
10. Children’s Hospital of Philadelphia. Vaccines and autism. May 7, 2018. Accessed March 20, 2022.
11. CDC. Vaccines do not cause autism. Reviewed December 1, 2021. Accessed March 20, 2022.
12. Children’s Hospital of Philadelphia. Do babies get too many vaccines? March 6, 2020. Accessed March 20, 2022.

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