Addressing Hesitancy of Pediatric COVID-19 Vaccination


Tina Tan, MD, and Sean O’Leary, MD, give examples of how to address parental hesitancy to vaccinate children against COVID-19.

Tina Tan, MD: What are some of the most important steps that pediatricians and other healthcare professionals can take to promote the widespread adoption of COVID-19 vaccination and to address vaccine hesitancy and misinformation? Because I know all of us are dealing with this every day.

Sean O’Leary, MD: This is the million-dollar question, right? I think it’s multifactorial. My area of research is immunization delivery. This is kind of what I do all day, every day, which is how do we increase our immunization rates? One thing I’ve learned working in this field for a while is there’s not one single thing that leads to high vaccination coverage. It’s lots and lots of little things all put together that are going to help stack up to the rates being over 95% in a lot of cases for our childhood vaccines. It’s not one simple thing. It’s many, many things like immunization information systems, having a periodicity schedule for well-child checks, school, and childcare immunization requirements. Recall, there are all these different things that we do to maintain these high rates. There are lots of things that can be done that may not seem like they are addressing, quote-unquote, vaccine hesitancy, but they’re all grounded in behavioral science. In some ways, they can be considered little nudges that move people along this spectrum toward vaccination.

All of those things matter. Things like having everyone on the same page, in terms of vaccinations, in your office is important, and that everyone in the clinic is offering the same message that yes, this matters. Especially since, in a lot of cases, families may be a little nervous to ask the physician what they think, but the medical assistant, they may be able to relate to a lot better. So, making sure everyone’s on the same page in terms of recommendations is important. I think it’s also fair that we’re in a place where we can use presumptive recommendations for COVID-19 vaccines. If I see someone due for the COVID-19vaccine, we can get that done today, something along the lines of that, rather than, have you thought about it? Would you want to get into the COVID-19 vaccine today? Presenting the COVID-19 vaccine in a firm manner is important and explaining the protocol with specific detail.

Families that are perhaps on the fence may be more likely to get the vaccine with that approach. Certainly, every pediatrician in the US who has recommended COVID-19 vaccines has gotten some pushback, some more than others and, in some cases that are really unfortunate, people can get angry and whatnot. Although, I still think it’s standard of care. I still think we should be approaching it as such, basically recommending the same way we do other vaccines. Now, once you get that pushback, you can sense when you don’t want to go further. If someone is clearly angry, you use your pediatric magic to defuse that situation. We’ve all had to do it and move on to the next topic. But most families, they do trust you, and they want to hear what you have to say.

We are our own group and others have done a lot of work around the use of motivational interviewing [MI] in these conversations. So that’s usually what we call it to pivot with MI, so you presumptively recommend the vaccine. Then, if you meet some pushback, you move into motivational interviewing. And I’ll just give a couple of examples of how that might look. One of the things that you often end up falling into is sort of a polite argument where we just try to persuade a family. They argue for all the reasons they don’t want to get it, and then they’re sort of strengthening their resolve against it. So, you really want to use that MI spirit, which a lot of people have at least heard of MI and most medical schools and even residency programs are training in motivational interviewing now.

Trying to pitch that we’re on the same team is sort of the concept. Guiding the conversation in a way that it’s really effective communication as opposed to an argument is important. So, you really want to avoid arguing about these points.

It is important that you’re reflecting, you’re asking, and you’re listening to their concern. Providing information on the importance of vaccinations, even in the current state of the pandemic, is important. What the psychologists and the MI trainers will tell you is that it’s not going to work every time, but it lowers the resistance of the person you’re talking with. They may be more receptive to the information you’re then going to share as opposed to if you just lay it on him. Especially when they’ve given you sort of this little psychological trigger that it’s OK to share it.

Another thing we recommend is autonomy support. So, pointing out areas that are really important that the patient should recognize is crucial in their decision-making process. That often will also further lower that resistance. By no means does MI work every time, but at least in studies, it’s another one of those things that increases our vaccination coverage and probably a few percentage points.

Tina Tan, MD: No. Those are really great tips. Because once you get the patient who’s arguing with you, and they keep on arguing with you, you’re not going to get anywhere with them.

Sean O’Leary, MD: Absolutely not.

Tina Tan, MD: I think what’s important is that you try and provide information that is based in science, not on social media, or these other avenues that these individuals can understand and maybe considered. Explaining that this is going to be good for the child as opposed to being detrimental.

Sean O’Leary, MD: The other thing I should mention, and this sort of falls into the general concept of less is more, is to avoid what people call the lecture trap, or the data dump trap. Physicians, in particular, are very prone to this, and by that I mean, this is true across our practice, not just in vaccine conversations. We’ve gone through college. We’ve gone through medical school. And we’ve gone through training with however many years of experience. We know a little something, and pediatricians in general are very giving people. We want to share what we know. The problem when you get into this lecture trap, or data dump, which I am prone to, is having all this information you want to tell them all about it. That really tends to raise resistance in people. Because they may not think of themselves as experts, but they’ve read a bit or they’ve gone online. When you start unloading on them, you create this expert/nonexpert dynamic, where suddenly, they don’t want to hear anymore, and you’ve lost them. The other thing is you say a word that maybe has a little medical lingo to it, that they didn’t quite understand and then they get stuck on that word. They don’t hear anything else that you’re saying because they’re still trying to figure out what it was 30 seconds ago. So being careful in your communication and being clear without excess detail is important. Some families, of course, ask for that and that’s fine, but you really don’t want to do that unless they ask for it.

Tina Tan, MD: I know, because sometimes it backfires on you, and they start lecturing you on what they read on the internet or what they read on social media and then it just goes back and forth as an argument. Very interesting the social dynamics that go into all of this.

Sean O’Leary, MD: Definitely.

Transcript edited for clarity

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