How to Talk to Vaccine-Hesitant Parents

By Keith Kloor | April 8, 2014 4:26 pm

This tweet from today caught my eye:

The smart folks at ThinkProgress seem to have missed all the media coverage of this recent study, which found that, for those already suspicious or concerned about vaccines, images of sick children and dramatic, cautionary narratives “actually increased beliefs in serious vaccine side effects.”

This is a known as the “backfire effect,” a phenomena defined concisely here:

When your deepest convictions are challenged by contradictory evidence, your beliefs get stronger.

Two of the researchers (Brendan Nyhan and Jason Reifler) who have previously written about the “backfire effect” in the context of political issues, are the lead authors of the recent study on ineffective vaccine communication approaches. (I discussed their paper here several weeks ago.) The study’s results suggest that vaccine-hesitant parents are immune to pro-vaccine messages and scary warnings, leading the authors to ask:

how should physicians and public health agencies respond to parental questions about vaccine safety? This question is difficult to answer. For instance, while some have advocated that health professionals engage in dialogue with vaccine-hesitant parents, relatively little is known about which messages are effective in overcoming parental reluctance to vaccinate.

But some are working assiduously to discern which messages are effective. On this front, I was encouraged to learn recently about Julie Leask, a professor of public health at the University of Sydney, in Australia. (Hat tip to Dan Kahan, who also has relevant vaccine-related papers here and here.) Leask has written about her work here and here and laid out seemingly effective communication approaches in this 2012 paper.

Several weeks ago, I had an email exchange with Leask, in which she elaborated on her research findings. Below is a lengthy excerpt from her that spells out some of the strategies now being used to communicate with vaccine-hesitant parents:

The immunisation social research field has come a long way since parents were dichotomised into the unhelpful labels of pro- or anti- vaccine. First, there is a spectrum of positions parents can have on vaccination – unquestioning acceptance, cautious acceptance, hesitance, delaying or selectively vaccinating and not vaccinating at all. Second, parents may move between these positions over time

The key is in health care providers first finding out where parents are at. Our research estimates that about half of all parents have no concerns and will just have their child immunised without thinking much about it – or they will even be vocal advocates. Another 40% have just a few questions or concerns. About 12% have a lot of questions or concerns and will either fully or partially vaccinate their child and only about 2% don’t’ vaccinate at all because they have so many concerns about vaccination.

Those hesitant parents – if their concerns are not addressed well can end up not vaccinating at all. That discussion with their doctor or nurse is pivotal. So in using a tailored approach, four things are helpful:

1. Find out where parents are at on this spectrum.

2. Establish flexible goals according to where they are at. A lot of time is wasted arguing with a mum who has no intention of vaccinating when it would be much better to keep the discussion brief but aim to leave the door open for future discussion. On the other hand, if mums or dads are genuinely concerned but have some motivation to vaccinate,  health professionals might like to invest a bit of extra time with them. Maybe make another appointment.

3. Use the most appropriate strategy to meet those goals. For hesitant parents, motivational interviewing techniques might help. They use a guiding style, instead of a directing style. This can still start with a confident recommendation about vaccination. But it then finds out where parents are at. There is a lot of focus on resisting the temptation to right wrong information. It is much better to first understand what those concerns are and what might be their source. For example, there might be a family member who had a reaction to a vaccine. Having established their level of confidence and concern about the vaccine the second part of motivational interviewing is exploring a parent’s own motivation to vaccinate. By getting them to voice that, they verbally engage the positives of vaccination and the health professional has the opportunity to elaborate on any point the parent might have made. This is true engagement instead of the top down paternalism that inevitably fails with such parents who tend to value their autonomy a great deal.

4. Use quality information, targeted to the parent’s needs. There are many vaccines on the schedule for children and hence much to communicate. If possible, it is better to get the information ahead of time. If not, providing some basic information about the vaccine and also what side effects to expect is very important to parents.

As parents or patients, we all want our questions to be taken seriously and answered well. It is normal to want to know about the few risks of vaccination, along with what sort of diseases they are protecting babies and children against. Recognising that parents come from a genuine wish to protect their children but also be confident in the vaccines they are having is important. For example, about one quarter of parents are concerned about the effect of vaccines on the immune system of their young baby. This is an intuitive concern that can be readily addressed. But health professionals we often need to resist the temptation to hear a concern we think is wrong and jump in to ‘right the wrong’. That is why communication science advises professionals to resist the righting reflex but use a guiding style. 

  • mem_somerville

    Thanks for the links to the papers. I’m interested to see what the success rate of this “guiding” style is. And I’d be willing to give it a try.

    That said, it’s hard to imagine it scaling effectively, or how it works in situations that aren’t one-on-one with the MD. For other topics (non-vaccine) those situations aren’t quite so common.

    • JH

      “it’s hard to imagine…how it works in situations that aren’t one-on-one with the MD”

      Indeed. At first I was going to say that it doesn’t work in those situations, but the more I think about it the more I see that it works quite well, for all but the “anti” crowd. It’s just that you intuitively distinguish the other groups and respond appropriately.

      But if, for example, you’re debating on blogs, you most likely zero in on the person that’s making declarative statements that are false, which changes the situation: A) you won’t have a follow-up appointment with that person; B) you’re not in a position of authority; and C) and perhaps most importantly – you have an audience.

      If the person is already making false declarative statements, It’s really not worth the trouble of trying to convince that person. So forget about them. Your target is the audience that’s reading but not commenting because they’re less certain of what position they should take. IME, in these cases you go for the jugular. Stick to quality information, avoid personal attacks, admit what you don’t know, but don’t hesitate to nail that person with facts, to say “no, you’re wrong, here’s why”.

      You may disagree with the last part, but I think the most important thing to remember is that your after the audience. The person making false statements provides an excellent foil.

      • mem_somerville

        I’m trying how to figure out how to schedule a second appointment with the most avoidant. In my experience (blogging on a librul web site), the people who needed to have the information the most avoided it, just dismissing it out-of-hand.

        But yeah, I still don’t see data on the effectiveness of this strategy. It’s kind of a proposal from what I read so far.

        • JH

          ” I still don’t see data on the effectiveness of this strategy.”

          I don’t know what to tell you about that. If you have a sensible strategy it will probably work – over several years.

        • JH

          Just out of curiosity, why are you so concerned to get data to show some communication method “works”?

          I think if you look at the climate debate, you’ll find the “climate concerned” are constantly fooling themselves with “data” on how to communicate so that their opinions stick. The more data they gather and the more they act on that data, the deeper in the hole they seem to get.

          The problem with getting data is that the data often isn’t reliable. I think that’s for a variety of reasons, but the biggest one is probably that people’s ideas of how to act in certain situations are often far more complex and nuanced than surveys can assess.

          Overall, as I think about it more, I think Leask’s approach is solid, because it recognizes and makes accommodations for many of the potential pitfalls, in addressing issues like vaccines.

  • mutatron

    You need to get someone to edit your writing.

  • JH

    “First, there is a spectrum of positions parents can have on
    vaccination…Second,
    parents may move between these positions over time”

    I guess that pretty much confirms what I wrote yesterday: people aren’t as fixed as they’re made out to be.

    As far as the rest of it goes, you can call it what you want, but it’s mostly just sound basic communication. If you start by, in effect, saying “look, I’m smart and your stupid and here’s why” don’t expect to gain much traction. I can’t see why we need research to tell us that.

    But it’s interesting that the “I’m-smart-your-stupid” position is basically the position of many of the “climate concerned.” The message is: don’t think for yourself on this. We know better.

  • 808maui

    I would like to know if the author of this article is aware of the FDA’s own study about Pertussis vaccine?

    FDA study helps provide an understanding of rising rates of whooping cough and response to vaccination

    ” This research suggests that although individuals immunized with an acellular pertussis vaccine may be protected from disease, they may still become infected with the bacteria without always getting sick and are able to spread infection to others, including young infants who are susceptible to pertussis disease.”

    http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm376937.htm

    If she was aware, and she she certainly should have been, then this is article is just a fluffly PR campaign to encourage vaccination by using people’s emotions including these poor parents to do something that does not even serve the purpose of protecting infants and people that can not get a vaccine.

    If she was being honest, she should say that the ONLY people who can NOT spread the bacteria to others is people who actually had the disease and have since recovered. Instead this is making people believe that if another child or person is vaccinated then they are safe to be around their infant or compromised child and the science, straight from the FDA themselves does not show this to be true!

    This entire article is calling whooping cough a vaccine preventable disease which it is clearly NOT. And it is telling people that everyone must vaccinate for the sake of “herd immunity” to protect others when it is clear that the only thing that can come close to creating herd immunity is people who are naturally immune.

    This is very simple and logical, coming right from the FDA, although they do not mention about natural immunity in their “announcement” if you read their actual research it is clearly shown.

    I personally am not aniti vaccine, I am personal benefit verses personal risk for any individual vaccine, medicine or drug.

    These types of articles are the very reason the public mistrusts vaccines and the so called experts. Articles like cause them to lose all credibility and are actually creating a dangerous situation by making people believe their children are safe around people who have been vaccinated against whooping cough when it is clear that vaccinated people are no more safer then unvaccintated and might be less safe because they may have no outward symptoms of disease.

    It appears that the vaccine does give some temporary immunity to getting symptoms which is a good thing by itself ( without regard to any cons or risks ).

    But that is not the point of this article, this article is about blaming parents and trying to shame them into doing something which does not even work.

    I feel bad for the parents of the children who got sick or died but they are being led to believe that the vaccine either would have saved their child, or, if others were vaccinated their child would still be alive, but that simply may not be the case at all.

    As an RN this kind of thing makes a mockery of “healthcare” and it is NOT science.

    Articles like these do more harm then good and it is no wonder more people are saying no to all vaccines and have stopped listening to “The Experts”.

    • JH

      The FDA says:
      “…none of the vaccinated animals developed outward signs of pertussis disease…”

      You say:
      “the vaccine does give some temporary immunity to getting
      symptoms”

      What gives?

  • Steve Crook

    Ahhh yes, the shouty brigade. They’re so much like the sterotype Brit abroad who, when confronted with a foreigner who simple refuses to speak English, talks at them LOUDLY and SLOWLY because then, surely, they’ll understand.

  • http://www.nurseswhovaccinate.org/ MelodyRN

    The nursing community has created a framework for the conversation with vaccine-hesitant parents. It’s called the CASE method and it’s shown to have positive influence when educating families.
    For those interested you can learn more here-
    http://www.mnaap. org/pdf/Making_the_CASE_for_Vaccines_MNAAP.pdf
    and
    http://pediatrics.aappublications. org/content/127/Supplement_1/S127.full

    Melody RN- Founder of Nurses Who Vaccinate

    • mem_somerville

      I can’t seem to get that first document–can you check the URL?

      • http://www.nurseswhovaccinate.org/ MelodyRN

        I put a space in before the “.org”- Disqus doesn’t always allow comments with urls in it so I had to break it up. Also try googling “Making the CASE for Vaccines”- Let me know if you find it!

        • mem_somerville

          Got it, thanks!

  • DrDenim

    Now the question: why would I want to?
    Darwinism will sort this out.

  • http://www.skepticalraptor.com/skepticalraptorblog.php Skeptical Raptor

    Yeah, it’s all well and good to be sweet and gentle with a group of vaccine deniers, whatever they are on this imaginary “spectrum” of vaccine acceptance.

    But someone has to smash down the lies of the antivaccine lunatics and cults out there. They don’t listen to scientific persuasion, so someone needs to be able to provide the strongly worded arguments to refute the lies of such groups as Age of Autism or NVIC.

    The rainbows and unicorns love fest for vaccine deniers is not going to work either, as long as the antivaccine groups push the lying liars who lie strategy.

    • mem_somerville

      Yeah. This is my natural niche in the scicomm ecosystem too–lie smashing and challenging the loudest liars and misinformers. Playing footsie with the malevolent is not something I can really do.

      Maybe it doesn’t work broadly, but I feel like it does energize the base. So maybe I’m not the right one to hand-hold the merely cautious. Fine–someone else can pick that up.

      Probably like most things–multiple strategies are best. But I’m getting really tired of being told that doesn’t work by people who haven’t demonstrated what does.

    • harrywr2

      They don’t listen to scientific persuasion

      Personally I think they are all nutters…having said that.

      All ‘effective’ propaganda contains a ‘grain of truth’ that is grossly embellished.

      Vaccines carry some nominal risk. The risk is not zero.

      So when someone says that a vaccine ‘could’ harm your child they are being truthful. So ‘smashing the lie’ won’t be effective.
      In fact it’s counter productive..

      You end up needing….

      “yes..there is a small probability that a child will have an adverse reaction to the vaccine…the probability that your child will contract a horrible disease without the vaccine is thousands of times more probable”….ends up being the effective discussion.

      Panic mongers make a living out of exaggerating risk…the way to counter them is by helping people to effectively weigh relative risks, not trying to convince the ‘fence sitters’ that there is no risk.

      Breathing involves taking a chance…most people understand this.

  • poniesinjudah

    1) yes
    2) no
    The basic idea here is sound (but let’s nix this spectrum talk. The correct term in science is subgroup). But far too rigid. And probably counter mnemonic. Some people are in a subculture of antivaccineness, others have been misinformed by that subculture. We want to give the latter accurate info. We want to give them something nice. Not make them behave. The latter attitude is common in medicine. A sneery attitude toward patients is an intrinsic element of the medical work culture.
    Also some people unsure about vaccines my feel that they have normal, skeptical Greenpeace-like info about them being bad. Those people can easily, by a well informed non bully, be shown what kind of weirdos the antivaccine people are. News clippings, videos. Info like in the Jenny McCarthy chapter in the Mnoukine book. And sincerity. A pleasant person who clearly wants your child to be OK is very different from being spoken to, no matter how politely, be someone who sees you as naughty, stupid and a pain. You can’t fake that sincerity. We need really good public health educators. And we REALLY need barrages of TV commercials. Like the antismoking ones in the 90s. That’s where the scary info about these diseases belongs. But NOT the scare tactics of cigarette package pictures. Narratives and olden days stories. “Brand” vaccine getting as modern.

  • JH

    Keith: here’s some fodder for a future post:

    Yesterday on our local NPR station there was a piece on the new “common core” educational standards. Apparently, the common core places a high priority on “evidence-based reasoning”.

    It sounds like a grand idea. Is it?

    The problem is that what constitutes “evidence” is subjective. For example, today skeptics claim that the “slow down” or “pause” (SDP) in warming is “evidence” that climate models aren’t reliable. OTOH, the Climate Concerned claim either: a) there is no SDP; or b) that the SDP isn’t relevant to the reliability of climate models, and therefore isn’t “evidence” of anything.

    So which is right? Is it “evidence” or is it not?

    Now, getting back to the common core, what’s the purpose of teaching “evidence-based reasoning”? IMO, the concept of evidence-based reasoning has become important recently in Liberal circles because of the inability of Libs to convince people that climate legislation is important. The feel that if they teach “evidence-based reasoning” all their problems with vaccines, creationism and climate change will go away.

    Will they? Will “evidence-based reasoning” instruction save the day? Or will the subjective nature of “evidence” undermine this effort?

  • Joshua

    So based on the “backfire effect,” what do you think about the effectiveness of calling people “loons?”

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Collide-a-Scape is a wide-ranging blog forum that explores issues at the nexus of science, culture and society.

About Keith Kloor

Keith Kloor is a NYC-based journalist, and an adjunct professor of journalism at New York University. His work has appeared in Slate, Science, Discover, and the Washington Post magazine, among other outlets. From 2000 to 2008, he was a senior editor at Audubon Magazine. In 2008-2009, he was a Fellow at the University of Colorado’s Center for Environmental Journalism, in Boulder, where he studied how a changing environment (including climate change) influenced prehistoric societies in the U.S. Southwest. He covers a wide range of topics, from conservation biology and biotechnology to urban planning and archaeology.

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