Monday, February 9, 2015

Effective vaccine counseling: ask, acknowledge, respond

- Jennifer Middleton, MD, MPH

The current U.S. measles outbreak has brought the complex issue of vaccine hesitancy back into the limelight. As of January 2015, 102 individuals in the U.S. contracted measles, along with 644 in 2014; this current outbreak seems to have originated at a Disney theme park in California, though the U.S. Centers for Disease Control and Prevention (CDC) has yet to identify the index case.

The CDC states that the "majority of the people who got measles were unvaccinated." Despite Dr. Andrew Wakefield's public shaming and a robust evidence base to the contrary, there are many Americans who believe that vaccines are unsafe.

It can be tempting to adopt a firm line with parents who refuse vaccinations for their child(ren); the American Academy of Pediatrics even has a vaccine refusal form physicians can have parents sign that outlines the risks of missed vaccinations. As physicians, we see the science in favor of vaccines along with the consequences of missed vaccines. We get frustrated at the inaccurate anti-vaccine information that can be found online. But if we channel that energy into using the same techniques we use to help our patients change other health-related behaviors, we just might increase vaccination rates.

For starters, it may help to remember that most parents want the best for their child(ren), as the authors of this 2011 Pediatrics article, Drs. Healy and Pickering, state:
Parents are attempting to make the best decisions on behalf of their children, a task made more difficult by many potentially conflicting sources of information. Parents may be more fearful of committing harm (giving an unsafe vaccine) than allowing harm (taking a chance that their child will develop a disease).
We need to ask parents about their worries, and acknowledge them, before responding with our expertise. Identifying parents' specific concern(s) allows physicians to appropriately target their counseling. Drs. Healy and Pickering identified the top three vaccine safety fears; for parents worried about autism (#1), we can describe the overwhelming evidence that vaccines do not cause autism. For parents worried about thimerosal, (#2) we can share that thimerosal is safe and also is rarely used in our current vaccines. For parents worried about immune system "overload" (#3), we can talk about how their child's immune system is capable of handling exponentially more antigens than vaccines will ever present. Targeting our counseling to parents' specific concerns may increase the likelihood of a decision to vaccinate.

A 2008 study found that the majority of parents who changed their mind about vaccination did so after obtaining additional information and/or "health assurances" about vaccine safety. Listening with genuine interest about why parents are worried about vaccination, and exploring these ideas with them in a non-judgmental way, may yield greater success than yielding to frustration. A parent-physician relationship grounded in trust also contributes to higher vaccination rates.

If you'd like to read more, there's an AFP By Topic on Immunizations (excluding Influenza) that includes links to patient information, Family Practice Management articles on increasing your office's vaccinations, and this AFP Journal Club discussing the evidence base behind the current measles vaccination recommendations.

What strategies are you using with vaccine-hesitant parents?