The Struggle to Convince Vaccine-Skeptical Parents

A two-part communication strategy that included discussing vaccine concerns with skeptical parents was not effective in boosting immunization among their children, according to a new study published in JAMA Network Open.

Researchers tested the combined effects of two techniques to increase vaccine uptake — presumptive language and motivational interviewing — on around 9srcsrc parents with negative attitudes about vaccines. They found no difference in vaccination uptake between patients whose pediatricians used the methods and those who received usual care.

Presumptive language involves bringing up the vaccine as a declarative statement, as in “Sara is due for two shots today,” rather than asking, “How do you feel about vaccines today?” the study authors wrote.

Motivational interviewing involves following-up with a short conversation to understand a parent’s hesitation and discuss their concern

“It’s not meant to be directive and persuasive, it’s meant to help clinicians pause, be curious, understand, and then partner with parents and provide medical information about vaccines tailored to what they are concerned about,” said Douglas Opel, MD, professor of pediatrics at the University of Washington School of Medicine in Seattle and lead author of the study.

While some persuasion can take place in motivational interviewing, clinicians don’t lead with it, Opel said.

The randomized controlled trial took place at clinics in Colorado and Washington State between 2src19 and 2src23. English- and Spanish-speaking parents with negative attitudes about vaccines and infants up to 2 months old were enrolled. Close to half had an annual household income of more than $75,srcsrcsrc, and nearly three fourths had some postsecondary education. 

The researchers found no difference between the intervention and control groups for percentage of days underimmunized (adjusted incidence rate ratio, 1.src6; 95% CI, src.69-1.63) and odds of being fully up to date for all immunizations through age 19 months old (adjusted odds ratio, 1.45; 95% CI, src.69-3.src4).

However, they found geographical differences: Kids in Washington State had a nearly two-and-a-half–fold chance of being fully on time with all of their immunizations through age 19 months old.

“We don’t understand why there were these state differences, but it gives us some idea that there’s potential for this strategy to work,” said Opel. He plans to do a nationwide study that can further indicate the influence of geography.

Regarding the differences, “it would be interesting to see if political or urban vs rural divides account for the variations in vaccine uptake,” said Tim Joos, MD, MPH, dual-certified pediatrician and internal medicine physician at Neighborcare Health in Seattle.  

Both presumptive language and motivational interviewing have been effective in previous research but not in combination, said Opel. Additionally, previous studies have focused on a single vaccine and an adolescent study population and have consisted of parents with mixed rather than solely negative attitudes towards vaccines.

The study results were not surprising to Karalyn Kinsella, MD, pediatrician in Cheshire, Connecticut. “Parents tend to come in with their minds made up,” she said.

Kinsella uses presumptive language in her practice and allocates a limited amount of time to follow-up questions.

“If I take 5 minutes of a visit to talk about vaccines, that’s too much time,” said Kinsella. “Generally, there’s only a few questions I can ask. And what happens over time is that if you get shot down enough times, you tend to not take that time anymore.”

The methods tested might feel pushy to parents who are already reluctant to get their child vaccinated, said Joos. Alternatives he suggested include stating what vaccines are due and asking if it’s ok to proceed, offering just the most important age-appropriate vaccines to highly hesitant parents, and avoiding presumptive language with parents who have a track record of refusing vaccines, he said.

“Asking ‘what vaccines would you be interested in today’ might work better with those families,’” Joos said. “I feel sometimes we have to act more like a salesperson, avoiding threatening any reluctant customers and using a more foot-in-the-door incrementalist approach.”

Kinsella believes that the best use of resources and research would be to establish more of a presence where parents are getting their vaccine information: Online and on social media.

“We need to be in those spaces giving facts and medical information,” Kinsella said.

The study was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and Jaxon’s Cure. Opel reported receiving grants from the National Institutes of Health (NIH) during the study and declared that the University of Washington holds the copyright for the Parent Attitudes about Childhood Vaccines (Registration No. TX 7-548-636), which was developed by Dr Opel and a version of which was used in this study. Dr O’Leary reported receiving grants from the Centers for Disease Control and Prevention and the NIH during the conduct of the study. Kinsella and Joos had no relevant financial conflicts of interest.

Brittany Vargas is a journalist covering medicine, mental health, and wellness.