If you ever wander into a holistic parenting group or a vaccine group that claims to offer “both sides” to educate folks about vaccines, you will, or at least you should, quickly notice that all of the posts and replies sound eerily alike.
If a parent asks about a tetanus shot for their child’s wound in one of these groups, no one will suggest that they rush to their pediatrician and get it.
The only disagreements you might see are whether they should treat the wound with colloidal silver, black salve, garlic, urine, activated charcoal, tea tree oil, raw honey, essential oils, or some other non-evidence based therapy.
It is no accident that folks get uniform advice against vaccines in these so-called vaccine “education” groups.
Anyone who goes against the “vaccines are dangerous” mantra of these groups typically has their comments quickly deleted and gets banned from the group.
“Echo chambers abound for many other conditions which are not medically recognised, from chronic Lyme disease to electromagnetic hypersensitivity. But perhaps most worrisome is the advance of anti-vaccine narratives across the web. The explosion of dubious sources has allowed them to propagate wildly, undeterred by debunking in the popular press. We might take the current drastic fall in HPV vaccine uptake in Ireland, driven by anti-vaccine groups like REGRET, despite its life-saving efficacy. While organisations including the Health Service Executive have valiantly tried to counter these myths, these claims are perpetuated across social media with little to stop them.”
Echo chambers are dangerous – we must try to break free of our online bubbles
After all, it is easier to feel confident in your decisions when you think that everyone else is doing the same thing. Of course they aren’t though. The great majority of people vaccinate and protect their kids.
It is only in these echo chambers of anti-vaccine misinformation that anyone would think that it would be okay to not get an unvaccinated toddler proper treatment for a cut, to skip a rabies shot after exposure to a rabid bat, or to not get travel vaccines before visiting high risk areas of the world.
That’s the power of confirmation bias.
And whether or not you realize it, confirmation bias is likely one of the reasons that you aren’t vaccinating and protecting your kids.
That’s why you need to step out of these echo chambers if you want to understand that vaccines are safe and necessary.
What to Know About Anti-Vaccine Censorhip
Anti-vaccine groups routinely censor, ban, and block messages from people who correct misinformation about vaccines and vaccine-preventable diseases.
What actually happens when a pediatrician has a vaccine policy that requires parents to vaccinate their kids or face dismissal from the practice?
Not surprisingly, there are a lot of myths about the controversial issue of pediatricians dismissing families who don’t vaccinate their kids.
1 ) It is a myth that the American Academy of Pediatrics has a policy encouraging pediatricians to dismiss families who don’t vaccinate their kids.
There is no such policy.
Instead, in 2016, about 400 leaders from AAP chapters, committees, councils, and sections voted on a resolution at the 2016 AAP Annual Leadership Forum (ALF) to support pediatricians who dismissed families who didn’t vaccinate their kids.
RESOLVED, that the Academy support, in their policy statements and clinical guidelines about immunizations, pediatricians who decide to discharge patients after a reasonable, finite amount of time working with parents who refuse to immunize their children according to the recommended schedule or who fail to abide by an agreed-upon, recommended catch-up schedule, and be it further RESOLVED, that the Academy continue to support pediatricians who continue to provide health care to children of parents who refuse to immunize their children.
Resolution #80.81SB Supporting Pediatricians Who Discharge Families Who Refuse to Immunize
The resolution also voiced support for pediatricians who didn’t dismiss these patients.
2) It is a myth that pediatricians dismissing families who don’t vaccinate their kids is a new thing.
Although it is getting a lot more attention now, since that 2016 resolution and a report on Countering Vaccine Hesitancy that soon followed, dismissing or firing families who don’t vaccinate their kids is not new.
A 2005 AAP report, Responding to Parental Refusals of Immunization of Children, discusses the issue.
“In general, pediatricians should avoid discharging patients from their practices solely because a parent refuses to immunize his or her child. However, when a substantial level of distrust develops, significant differences in the philosophy of care emerge, or poor quality of communication persists, the pediatrician may encourage the family to find another physician or practice.”
Responding to Parental Refusals of Immunization of Children
And a study, Dismissing the Family Who Refuses Vaccines, also published in 2005, made it clear that many pediatricians “would discontinue care for families refusing some or all vaccines.”
3) It is a myth that dismissing families who don’t vaccinate their kids is an evidence based policy.
There is nothing beyond anecdotal evidence that families, when faced with the decision of getting vaccinated or getting dismissed from an office, will choose to get vaccinated.
Again, the latest resolution supporting the idea of dismissing families came because it was voted on and became an official Annual Leadership Forum resolution. In general, only the top 10 ALF resolutions are acted upon urgently by the AAP.
At the time, many pediatricians felt constrained by the previous statements from the AAP that discouraged dismissing these families.
4) It is a myth that pediatricians dismiss families who don’t vaccinate their kids because they don’t want to be bothered talking about vaccine safety.
Although few pediatricians would want to talk to a parent who is arguing that vaccines are poison, aren’t necessary, and never work, fortunately, most vaccine-hesitant parents don’t actually talk like that. They are usually on the fence or simply scared because of all of the anti-vaccine propaganda they are exposed to and need a little extra time to understand that vaccines are safe and necessary.
And most pediatricians give them that extra time and do talk to them about their concerns. Despite the perception from some of the headlines you might see, families typically don’t get fired after one visit because they refused one or more vaccines.
5) Pediatricians who don’t dismiss unvaccinated families are supporting the use of alternative vaccine schedules.
While this is certainly true for some providers who actually advertise that they are “vaccine-friendly” and encourage parents to follow a non-standard, parent-selected, delayed protection vaccine schedule, most others understand that there is no evidence to support these alternative schedules and they are simply tolerated until the child can get caught-up with all of his vaccines.
6) It is illegal to dismiss a family who doesn’t want to vaccinate their kids.
While some pediatricians think that it is a bit of an ethical dilemma, the legal issues are very clear.
Physicians can’t simply abandon a patient so that they go without care, but they are typically free to end the physician-patient relationship after giving them formal, written notification, and continuing to provide care (at least in emergency situations) for a reasonable amount of time, giving the family time to find a new physician.
Of course, state and federal civil rights laws protect families from being terminated because of sex, color, creed, race, religion, disability, ethnic origin, national origin, or sexual orientation.
7) It is a myth that dismissing families who don’t vaccinate their kids will protect those families who do vaccinate and protect their kids.
This is often the main reason that pediatricians use to justify dismissing families who don’t vaccinate their kids. After all, it isn’t fair to the families who come to your office, those who do get vaccinated and protected, if someone who is intentionally not vaccinated gets measles and exposes them all, right?
There seem to be several problems with this idea though:
relatively few exposures during outbreaks actually occur in a pediatrician’s office. Looking at most recent measles outbreaks, for example, exposures were more likely to occur while traveling out of the country, in an urgent care center, emergency room, somewhere in the community, or in their own home.
infants who get pertussis are usually exposed by a family member
while measles is very contagious and the virus can linger in an exam room for hours, other vaccine-preventable diseases are far less contagious. Mumps, for example, typically requires prolonged, close contact, which is why you are unlikely to get mumps at your pediatrician’s office.
when dismissed by their pediatrician, there is a concern that families might cluster together in the offices of a vaccine-friendly doctor or holistic pediatrician, making it more likely for outbreaks to erupt in their community if any of them get sick
And that’s the key point. Just because families get dismissed from a pediatrician’s office, it doesn’t mean that they leave the community. Your patients might still see them at daycare, school, at the grocery store, or walking down their street.
With RSV, strep, cold viruses, and everything else that kids have in the average pediatrician’s office, it is best to take steps to reduce the chances that kids are exposed to all of them. How do you do that? Don’t have a waiting room full of kids that are exposing each other to germs!
8) Most families don’t vaccinate their kids because they don’t trust their pediatrician.
“In today’s world, smallpox has been eradicated due to a successful vaccination program and vaccines have effectively controlled many other significant causes of morbidity and mortality. Consequently, fear has shifted from many vaccine-preventable diseases to fear of the vaccines.”
Marian Siddiqui et al on the Epidemiology of vaccine hesitancy in the United States
“With all the challenges acknowledged, the single most important factor in getting parents to accept vaccines remains the one-on-one contact with an informed, caring, and concerned pediatrician.”
“…nearly half of parents who were initially vaccine hesitant ultimately accepted vaccines after practitioners provided a rationale for vaccine administration.”
“Developing a trusting relationship with parents is key to influencing parental decision-making around vaccines.”
“Pediatricians should keep in mind that many, if not most, vaccine-hesitant parents are not opposed to vaccinating their children; rather, they are seeking guidance about the issues involved, beginning with the complexity of the schedule and the number of vaccines proposed.”
“Because most parents agree to vaccinate their children, this dialogue, which can be started as early as the prenatal interview visit if possible, should be an ongoing process.”
“…it is important to recognise that the balance of media reporting does not necessarily reflect the balance of the argument among the involved professionals – by this is meant that equal weighting might be given by the media (and thus the lay community) to those for and against the vaccine although opponents of vaccination might be a very small number, as for example happened with both pertussis and MMR.”
David Baxter on Opposition to Vaccination and Immunisation the UK Experience – from Smallpox to MMR
understand the hierarchy of evidence and that a small study done in mice or a case report is probably not newsworthy, whereas a systemic review or meta analyses, especially if it was published in a high impact journal, is something we might need to hear about
Are you ready to cover your next story about vaccines or the next measles outbreak?
What to Know About Reporting on Vaccines
The way that health journalists cover vaccines and vaccine-preventable disease outbreaks can influence the behavior of people, either helping them understand that vaccines are safe and necessary, putting them on-the-fence about vaccines, or scarring them away from getting vaccinated and protected.
Having disagreements about getting kids vaccinated and protected are not rare these days.
“Many parents have questions about their children’s vaccines, and answering their questions can help parents feel confident in choosing to immunize their child according to the CDC’s recommended immunization schedule.”
They understand that terminating the physician-patient relationship over vaccines truly is a last resort for “when a substantial level of distrust develops, significant differences in the philosophy of care emerge, or poor quality of communication persists.”
Whether you find yourself on opposite sides about immunizations with a friend, your spouse, an ex, or your pediatrician, agree to get educated about vaccines using these recommended and reliable sources of information and then talk about it some more.
In addition to seeing future immunization workshops and conferences that you might be interested in attending, here are many archived workshop videos, presentations, slides, and posters that you can watch and read online:
National Immunization Conference – sponsored by the CDC and HHS, the NIC has been bringing together a wide variety of local, state, federal, and private-sector immunization partners to explore science, policy, education, and planning issues related to immunization in general and vaccine-preventable disease for over 48 years.
Current Issues in Immunization NetConference (CIINC) – scheduled 4 to 5 times per year, these live, 1-hour presentations combine an online visual presentation with simultaneous audio via telephone conference call and a live question and answer session.
Got Your Shots? Immunization Conference – this 2016 Minn DOH immunization conference had presentations on social media, social norming, incorporating new best practices, how to give a strong vaccine recommendation, and why we vaccinate
UNSW Immunisation advocacy workshop – a 2015 workshop that focused on increasing immunization rates for existing vaccines using media advocacy, grass roots citizen advocacy, and government and political processes.
Have you been to an immunization conference this year?
What to Know About Immunization Workshops and Conferences
Immunization conferences are a great way to learn about childhood and adolescent immunizations, vaccine preventable diseases, implementing appropriate immunization communication strategies, and addressing vaccine hesitancy.
“Our systematic review did not reveal any convincing evidence on effective interventions to address parental vaccine hesitancy and refusal. We found a large number of studies that evaluated interventions for increasing immunization coverage rates such as the use of reminder/recall systems, parent, community-wide, and provider-based education and incentives as well as the effect of government and school immunization policies.
However, very few intervention studies measured outcomes linked to vaccine refusal such as vaccination rates in refusing parents, intent to vaccinate, or change in attitudes toward vaccines.
Most of the studies included in the analysis were observational studies that were either under-powered or provided indirect evidence.”
Sadaf et al on A systematic review of interventions for reducing parental vaccine refusal and vaccine hesitancy
It’s that we don’t really know how to talk about vaccines to vaccine hesitant parents, at least not in a way that we know will consistently get them to vaccinate and protect their kids.
Understanding Studies About Vaccine Hesitancy
Sure, a lot of studies have been done about talking to vaccine hesitant parents.
We have all seen the headlines:
Study: You Can’t Change an Anti-Vaxxer’s Mind
Pro-vaccine messages can boost belief in MMR myths, study shows
UWA study shows attacking alternative medicines is not the answer to get parents to vaccinate kids
Training Doctors To Talk About Vaccines Fails To Sway Parents
Does that mean that you shouldn’t try to talk to vaccine hesitant parents?
Of course not.
“How providers initiate and pursue vaccine recommendations is associated with parental vaccine acceptance.”
Opel et al on The Architecture of Provider-Parent Vaccine Discussions at Health Supervision Visits
Just understand that these headlines are usually about small studies, which if they were about treating a child with asthma or strep throat, likely wouldn’t change how you do things.
In one study that concluded that “physician-targeted communication intervention did not reduce maternal vaccine hesitancy or improve physician self-efficacy,” the physicians got a total of 45 minutes of training!
So they shouldn’t have so much influence about how you might talk to parents about vaccines that you throw up your hands at the thought of talking to a vaccine hesitant parent and won’t even think about learning how to use the CASE method, why presumptive language might work, or about vaccination-focused motivational interviewing techniques.
The bottom line is that no matter what the headlines say, we just haven’t found the best way to talk to vaccine-hesitant parents and help them overcome their cognitive biases. And until more studies are done, none of the existing studies about anti-vaccine myth-busting should likely overly influence how you do things.
“Physicians should aim for both parental satisfaction and a positive decision to vaccinate. Researchers must continue to develop conceptually clear, evidence-informed, and practically implementable approaches to parental vaccine hesitancy, and agencies need to commit to supporting the evidence base. Billions of dollars fund the research and development of vaccines to ensure their efficacy and safety. There needs to be a proportional commitment to the “R&D” of vaccine acceptance because vaccines are only effective if people willingly take them up.”
Leask et al on Physician Communication With Vaccine-Hesitant Parents: The Start, Not the End, of the Story
If you spend any time talking to vaccine hesitant parents, especially those who are on the fence, you quickly learn that many are eager to get good information about vaccines and all want to do what is best for their kids.
“…while the drivers of vaccine hesitancy are well documented, effective intervention strategies for addressing the issue are sorely lacking. Here, we argue that this may be because existing strategies have been guided more by intuition than by insights from psychology and by the erroneous assumption that humans act rationally.”
Rossen et al on Going with the Grain of Cognition: Applying Insights from Psychology to Build Support for Childhood Vaccination
If a parent is concerned about glyphosate, you might not sound too convincing telling them not to worry if you don’t even know what glyphosate is.
What to Know About Vaccine Hesitancy Studies
While we learn better ways to talk about vaccines, so that vaccine-hesitant parents can more easily understand that vaccines are safe and necessary, don’t dismiss current strategies because of small studies and attention grabbing headlines.
One strategy that might work includes asking open ended questions about why the parent is hesitant to vaccinate their kids. Next, while responding to a few of their biggest concerns, be sure to affirm what the parent is saying and use reflective listening.
You are really worried that your child might get sick after their vaccines.
It sounds like you think kids get too many shots.
Now, address a few of those concerns.
Pediatricians often feel like they don’t have enough time to have long discussions about vaccines, when they also need to talk about many other important topics at each visit, including nutrition, development, and safety, etc. The vaccine talk doesn’t have to be extensive though. Just get it started and come back to it again at the next visit.
It is not enough to simply tell your vaccine hesitant parents to read a book, visit a website, or offer them some handouts though. It is important that pediatricians also talk to parents about vaccines.
Study after study show that pediatricians are the most influential, most convincing, and most used source of information about vaccines for many parents.
“How providers initiate and pursue vaccine recommendations is associated with parental vaccine acceptance.”
Opel et al on The Architecture of Provider-Parent Vaccine Discussions at Health Supervision Visits
Include stories and anecdotes about kids who have gotten sick and parents who regret not vaccinating their kids.
Become familiar with the anti-vaccine talking points that may be scaring your patients away from getting vaccinated on time. Why is this important? If they are concerned about glyphosate, you might not sound too convincing telling them not to worry if you don’t even know what glyphosate is.
Try the CASE Method for talking about vaccine concerns.
Are your kids fully vaccinated? Talk about that too.
There is much more to all of this than simply letting parents follow non-standard, parent-selected, delayed protection vaccine schedules and arguing with them about getting caught up.
What to Know About Talking to Vaccine Hesitant Parents
Learning new ways to talk to vaccine hesitant parents, including the use of vaccination-focused motivational interviewing techniques, presumptive language, and high-quality recommendations, might help pediatricians have more success and get less frustrated.