There are constructive ways to carry on difficult conversations with parents about immunization refusal or vaccine hesitancy.
Katrina Saba, MD, FAAP
Ken Hempstead, MD, FAAP
Communicating with vaccine-hesitant parents or those refusing to vaccinate is a challenge across the pediatric landscape. Whereas some pediatricians choose to argue, and some to even dismiss families who are not on board with vaccination, experts suggest there is another way.
Katrina Saba, MD, FAAP, chief of Pediatrics at Kaiser Permanente in Oakland, California, and Ken Hempstead, MD, FAAP, a pediatrician at Kaiser Permanente in Roseville, California, and immunization champion for Kaiser Permanente in the Sacramento area, led a discussion titled “Immunizations: Communicating without confrontation” on November 3 at the American Academy of Pediatrics (AAP) 2018 National Conference and Exhibition in Orlando, Florida.
The session highlighted tools and solutions for improving communication with parents who refuse or are hesitant to vaccinate their children. The presenters discussed the 4 tools of persuasion in vaccine communication to help clinicians become more comfortable and effective in dealing with vaccine refusal or hesitancy.
Conversation, not debate
Speaking before the conference, Hempstead told Contemporary Pediatrics that he hopes to help relieve pediatricians of the burden of debating vaccines with parents who refuse or are hesitant to immunize their children.
“This is not only exhausting and frustrating, but it’s also often counterproductive. Rather than trying to correct misinformation or provide facts-which often doesn’t work and can make matters worse-we teach pediatricians to align with these families, frame the conversation positively, and use other time-honored rhetorical tools to help families make the right decision to vaccinate,” Hempstead says.
This approach was adopted at Kaiser Permanente in 2013 in response to legislation in California that required parents to have a conversation about vaccination with their child’s pediatrician before being allowed to decline vaccines.
“There was recognition that this legislation would result in vaccine-hesitant families coming in to see their doctors for this conversation, and we acknowledge that what we have been doing wasn’t working because they still refused vaccines,” Hempstead says. “While we did not create this program with a study design in mind, we were able to do some data collection and surveying after it had been used for a time by pediatricians. We did find a modest increase in our already high vaccination rates.”
More importantly, a survey found that the program had boosted pediatricians’ confidence and comfort level in having these discussions.
“We certainly believe that anything that helps to optimize these conversations and make them more pleasant will in the long-run improve the doctor-patient relationship, and also ultimately improve vaccination rates,” Hempstead says. “While it is important to educate pediatricians about what techniques to avoid, such as not debating or correcting misinformation, it is just as important to teach them what they should do instead.”
By trying a new approach and avoiding the traditional rhetoric of handing down advice rather than having a conversation, Hempstead says pediatricians will not only get more of their families protected with vaccinations, but they also will feel more comfortable and satisfied, and less frustrated after these conversations.
To that end, Hempstead offers the following advice:
1. Make it easy to agree.
“People in a relaxed, nonconfrontational state are more open to your message and are more likely to agree,” he says. “When people feel that they are being challenged or are faced with a difficult decision, they tend to become more defensive and retreat toward or reinforce their own position.”
This is great advice for pediatricians, Hempstead says, because it allows them to avoid becoming upset during an unpleasant encounter with a parent and reminds them that these confrontations can lead to a loss in the clinician’s ability to persuade.
2. Have clear recommendations.
Be clear in what recommendations and expectations you have for any needed vaccinations at a visit, he says. Use statements rather than questions. “For example, rather than asking if you would like Sarah to get a flu shot today, say the following: ‘Sarah is due for 3 shots today, including her flu vaccine.’
3. Understand the role of identity in decision-making.
When disagreeing with parents about their beliefs, Hempstead says it’s also important to note that you are also disagreeing with the identify of their “group,” or whatever network they have supporting their beliefs.
“Rather than attack, try wherever possible to align with the parents’ identity, with statements such as ‘great parents ask great questions’ or ‘what we both want,’” Hempstead suggests.
4. Frame the conversation.
Frame conversations positively, using words such as “protection,” “safe,” and “healthy.” Hempstead recommends that pediatricians avoid getting into a conversation or argument about adverse effects, dangers, or other negative terms. Clinicians also should have realistic goals for their encounters.
“Remember that their beliefs are stronger than your evidence. Get curious, not furious,” Hempstead says. “Focus on your long-term relationship with the family and align with them-this will lead to success in the long run. Challenge yourself to try something new in these discussions.”