How to Connect with Vaccine-Hesitant Parents

Announcer:
You’re listening to On the Frontlines of Pediatric Vaccines on ReachMD. Here’s your host, Ashley Baker.

Ashley Baker:
Welcome to On the Frontlines of Pediatric Vaccineson ReachMD. I'm Ashley Baker, and joining me to discuss evidence-based communication strategies for improving childhood vaccine uptake is Dr. Douglas Opel. Dr. Opel is a Professor in the Department of Pediatrics at the University of Washington School of Medicine in Seattle. He's also the Director of the Truman Katz Center for Pediatric Bioethics and Palliative Care and the Associate Director of the Center for Clinical and Translational Research at Seattle Children's Research Institute. Dr. Opel, we're so glad to have you here today.

Dr. Opel:
Thanks for having me.

Ashley Baker:
Let's jump right in, Dr. Opel. How have parents' attitudes towards vaccines shifted in recent years, and how is that showing up in your conversations with them?

Dr. Opel:
This is a good question, and one that doesn't have a simple and straightforward answer. For instance, it depends on who is asked, how attitudes are measured, and really even what vaccines we're referring to.

But to give some understanding of how things might have shifted, studies recently that have asked pediatricians what their experience has been have largely found that pediatricians are finding more parents expressing new hesitancy regarding childhood vaccines.

And anecdotally, this resonates with me and my own practice. Though, when looking at national data of how parents report their own attitudes towards vaccines, the proportion of those parents who are vaccine hesitant actually has remained relatively stable from pre- to post-pandemic time periods, though we don't have more recent updates from this data set beyond 2022, so there, potentially, has been some shifts since that time period.

And then other studies have shown that hesitancy by parents varies by vaccines, with hesitancy towards measles, polio, and tetanus post-pandemic being relatively low compared with hesitancy toward COVID-19 and influenza vaccines.

So there's a variety of ways to answer this question. I think, anecdotally, most pediatricians would say there is a rise in vaccine hesitancy, and maybe that data from how parents report their own attitude to vaccines—although being relatively stable through 2022—might end up showing that actually is the case once we have that data analyzed through the current time.

Ashley Baker:
With that in mind, can you describe how a presumptive approach to vaccine discussions is typically used in practice and what clinicians aim to achieve with that style of communication?

Dr. Opel:
Sure. What you're referring to is how clinicians approach or begin the vaccine discussion with parents, and a presumptive format is one in which the clinician begins that conversation by asserting a position regarding vaccines using a closed-ended statement like, "Sarah is due for several vaccines today," or, "Well, we have to do some shots today."

Now, this format is just meant to be how this conversation begins with parents. There's a lot that comes after this—the parent's response, a discussion tailored to parent questions, etc. But starting off the vaccine discussion in this way has been found to be more effective than starting off the vaccine discussion with an open-ended question like, "How do you feel about vaccines today?” When that format is used, that open-ended question format, children receive less vaccines than if the presumptive format is used.

Now, we don't know exactly why this is, but we do know that there are well-known pitfalls in how humans in general make decisions, and these can provide insights. For instance, the presumptive format sets vaccination as the default—the condition that will occur if no alternatives are actively chosen. And this can leverage some of the cognitive biases that make it difficult to reverse a decision that appears to already have been made.

Ashley Baker:
When parents express hesitation or resistance, how is motivational interviewing incorporated into the conversation, and what are its intended goals?

Dr. Opel:
Well, it's important to be clear that use of the presumptive format is not 100 percent effective. While it is more effective at improving vaccine uptake than the open-ended question format, some parents will still voice resistance to vaccines even with use of that presumptive format. And in these situations, we need other techniques and strategies to help engage with families, understand their concerns, etc.

And motivational interviewing, or MI, is one of these strategies. This is a patient-centered framework for behavior change that really helps leverage one's own inherent motivations for behaviors. And this can help parents get more insight into their concerns and own motivations for not choosing vaccines now, but for maybe choosing vaccines down the road.

So several MI communication techniques that have been found to be effective, even in a short visit in which vaccines are discussed: include use of open-ended questions and use of affirmation statements or reflection statements. So all of these help clinicians understand parent concerns, encourage partnership with parents, and deepen rapport.

But, as I said, they also help parents gain insights into their own motivations regarding vaccines and what might help them feel more motivated to get their child vaccinated, either at that visit or at a future visit. MI has been found to be effective in several areas in medicine in discussing preventive care issues, and some evidence suggests that it can be effective in the vaccination discussion as well.

Ashley Baker:
For those just tuning in, you're listening to On the Frontlines of Pediatric Vaccines on ReachMD. I'm Ashley Baker, and I'm speaking with Dr. Douglas Opel about effectively communicating with vaccine-hesitant parents.

So, Dr. Opel, even when clinicians use both approaches—presumptive language and motivational interviewing—we don't always see a shift in parents' decisions. Knowing that, what other factors need to be considered when addressing vaccine hesitancy?

Dr. Opel:
So let me just elaborate on your first point. We recently conducted a randomized controlled trial—so a rigorous experimental study—in two states to test the effect of using both of these approaches: the presumptive approach for all parents when beginning the vaccine discussion, and then for those parents who continue to voice resistance, shifting to use of motivational interviewing.

And overall, we did not see an effect in vaccine uptake among children whose pediatricians used this strategy compared to children whose pediatricians did not. But what we did find is that, when we looked at vaccine uptake at the state level, we did see a significant effect in vaccine uptake among children in one of those two states among the group where pediatricians were using this strategy.

So we're not sure why this is, but it does suggest that this strategy may be effective in some instances, some geographic areas, and some contexts with some parents. So important for us to still think about the potential utility of that approach, the presumptive format, and pairing it with MI when parents continue to voice resistance.

Of course, there are other strategies to keep in mind. And these are strategies that pediatricians have focused on for years that have made them parents' most trusted resource on vaccines, and these are strategies rooted in collaboration, clear communication, and a commitment really to doing what's best for children.

Ashley Baker:
So, building on that, how can we best tailor our approach to each individual patient and their family?

Dr. Opel:
Well, I think it's important to approach each conversation with the mindset that the vast majority of parents are just trying to do what they think is best for their child. And so parent refusal of a recommended immunization therefore often simply conveys a difference in values from us, their child's clinician.

For example, the remote risk of a simple febrile seizure as a potential side effect of a vaccine may seem trivial to us as clinicians, but may be viewed as, by a parent, really life-threatening and horrific, and have them, as a result, be quite hesitant to accept that vaccine.

So I think approaching vaccines mindful of that can help us remember that sometimes a respectful exploration of these values and underlying concerns can be a helpful way to move the conversation forward.

Ashley Baker:
Before we come to the end of our discussion, Dr. Opel, do you have any final thoughts you'd like to leave with our audience?

Dr. Opel:
Well, I'll just end by acknowledging how much vaccine policy has changed in the last year in the United States. And amidst this turmoil, it's really helpful for pediatric clinicians to remember what has remained constant. And they have been and continue to be parents' most trusted source of reliable information about vaccines.

So at this critical time, I think it's important for us as clinicians to continue to strongly recommend vaccines as well as lean into some of these communication strategies we talked about that both draw on this existing trust and continue to nurture it with parents.

Ashley Baker:
With those important insights in mind, I want to thank my guest, Dr. Douglas Opel, for sharing his expertise on how clinicians can navigate vaccine hesitancy in conversations with parents. Dr. Opel, it was great having you on the program.

Dr. Opel:
Thank you.

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