MB Comment: This is a comic inside look at motivational training for pediatricians who encounter opposition from vaccine hesitant and vaccine refuser parents.
The authors of this study aren’t exactly the creme of the crop, but they do provide an inside look at the demented psychology of vaccine salesmen, errr I mean pediatricians. The sample doctor/vaccine resistant patient conversations at the end of this article are an absolute hoot.
Some key points from their article:
1) Unquestioning acceptors (30%-40%) have less detailed knowledge about vaccination.
2) Late or selective vaccinators (2%-27%) have the highest levels of knowledge about vaccination and prefer statistical arguments to anecdotal information.
3) Refusers (2%) say that contact with the medical establishment and doctors often results in feelings of alienation and disenchantment and they tend to prefer the advice of alternative health professionals. Duh.
4) Concerns about vaccine safety will increase as vaccination schedules inevitably become more complex (these drug company servants are planning WAY MORE vaccines for your children).
Thank goodness they publish this stuff openly so parents can be prepared for the weasel-speak they will encounter from pediatricians who follow this mumbo jumbo vaccine sales pitch. It’s psychological warfare.
You won’t find the most basic facts about vaccine safety or risks in this cesspool of salesmanship – i.e. The US Supreme Court has declared vaccines to be unavoidably unsafe, the medical textbook definition of a vaccine adverse reaction is encephalitis (brain inflammation), or vaccine package inserts list sudden infant death syndrome (SIDS), autism and encephalopathy under the serious adverse events section. In that sense, this roadmap for pediatric vaccine promotion is like a marketing manual for used car salesmen who are selling lemons: Don’t tell the customer about the defective products you are pushing. Sadly, the majority of parents will fall for this deception.
When you read this article, you should realize that you are not going to get anything but vaccine propaganda from cookie-cutter pediatricians.
So why not just ditch the pediatrician and get a qualified doctor you trust that is on your side about vaccine refusal, if you have legitimate concerns about vaccine safety and efficacy?
Communicating with parents about vaccination: a framework for health professionals
‘Five distinct parental groups were identified: the unquestioning acceptor (30–40%), the cautious acceptor (25–35%); the hesitant (20–30%); the late or selective vaccinator (2– 27%); and the refuser of all vaccines (<2%) …
In all encounters, health professionals should build rapport, accept questions and concerns, and facilitate valid consent. For the hesitant, late or selective vaccinators, or refusers, strategies should include use of a guiding style and eliciting the parent’s own motivations to vaccinate while, avoiding excessive persuasion and adversarial debates. It may be necessary to book another appointment or offer attendance at a specialised adverse events clinic …
The second factor, and the focus of this paper, relates to parents’ concerns about the safety or necessity of vaccines [4,5]. A critical factor shaping parental attitudes to vaccination is the parent’s interactions with health professionals. An effective interaction can address the concerns of vaccine supportive parents and motivate a hesitant parent towards vaccine acceptance [5,6]. Conversely, poor communication can contribute to rejection of vaccinations or dissatisfaction with care [7-9]. Such poor communication often results from a belief by the health professional that vaccine refusal arises from ignorance which can simply be addressed by persuading or providing more information. Such an approach is counter-productive because it fails to account for the complexity of reasons underpinning vaccine refusal and may result in backfire effect  …
These concerns will likely increase as vaccination schedules inevitably become more complex, and parents have increased access to varied information through the internet and social media …
We propose here a framework to guide health professionals in communicating with parents about vaccination … The framework is informed by evidence from decision making and communication research … The overarching goal of the encounter is to promote quality decisions and, ultimately, vaccination.’
Listen to the Refusers song Vaccination Uber-Alles
Communicating with parents about vaccination: a framework for health professionals
BMC Pediatrics 2012, Publication date 21 September 2012
Article URL http://www.biomedcentral.com/1471-2431/12/154
A critical factor shaping parental attitudes to vaccination is the parent’s interactions with health professionals. An effective interaction can address the concerns of vaccine supportive parents and motivate a hesitant parent towards vaccine acceptance. Poor communication can contribute to rejection of vaccinations or dissatisfaction with care. We sought to provide a framework for health professionals when communicating with parents about vaccination.
Literature review to identify a typology of parent attitudes or positions on childhood vaccination with estimates of the proportion of each group based on population studies. Development of a framework related to each parental position with determination of key indicators, goals and strategies based on communication science, motivational interviewing and valid consent principles.
Five distinct parental groups were identified: the unquestioning acceptor (30–40%), the cautious acceptor (25–35%); the hesitant (20–30%); the late or selective vaccinator (2– 27%); and the refuser of all vaccines (<2%). The goals of the encounter with each group will vary, depending on the parents’ readiness to vaccinate. In all encounters, health professionals should build rapport, accept questions and concerns, and facilitate valid consent. For the hesitant, late or selective vaccinators, or refusers, strategies should include use of a guiding style and eliciting the parent’s own motivations to vaccinate while, avoiding excessive persuasion and adversarial debates. It may be necessary to book another appointment or offer attendance at a specialised adverse events clinic. Good information resources should also be used.
Health professionals have a central role in maintaining public trust in vaccination, including addressing parents’ concerns. These recommendations are tailored to specific parental positions on vaccination and provide a structured approach to assist professionals. They advocate respectful interactions that aim to guide parents towards quality decisions.
The benefits of childhood vaccination are well established . Vaccine uptake rates in most industrialised countries are generally high. However, two broad parental factors are associated with under-vaccination. The first relates to socioeconomic disadvantage where, despite some motivation to have their children vaccinated, parents or carers (hereafter referred to as parents) lack access to adequate resources and support to overcome logistical barriers such as a lack of transport or childcare [2,3]. The second factor, and the focus of this paper, relates to parents’ concerns about the safety or necessity of vaccines [4,5]. A critical factor shaping parental attitudes to vaccination is the parent’s interactions with health professionals. An effective interaction can address the concerns of vaccine supportive parents and motivate a hesitant parent towards vaccine acceptance [5,6]. Conversely, poor communication can contribute to rejection of vaccinations or dissatisfaction with care [7-9]. Such poor communication often results from a belief by the health professional that vaccine refusal arises from ignorance which can simply be addressed by persuading or providing more information. Such an approach is counter-productive because it fails to account for the complexity of reasons underpinning vaccine refusal and may result in backfire effect . Parental vaccination decisions are based on an array of factors and parents integrate information according to their experiential and social contexts [11,12]. A parent’s trust in the source of information may be more important than what is in the information [13,14]. Health professionals have a central role in maintaining public trust in vaccination; this includes addressing parents’ vaccine concerns . These concerns will likely increase as vaccination schedules inevitably become more complex, and parents have increased access to varied information through the internet and social media . In recognition of the need to support health professionals in this challenging communication task conducted in usually short consultations, recommendations have been proposed [17-19]. Previously, most of these have focused on what is said, that is, the information that should be given to parents. Few have addressed how health professionals should engage with parents [17-21]. Since it is clear that parents want an improved dialogue about vaccinations [22-24], it is essential to focus on communication processes that build rapport and trust between the health professional and the parent [25-27].
We propose here a framework to guide health professionals in communicating with parents about vaccination. By focusing on both what is said and how it is said, we attempt to provide an integrated, generic approach going beyond simply the one-way provision of information.
The framework is informed by evidence from decision making and communication research and is applicable for use by all health professionals in their vaccination discussions, particularly where there might be parental reluctance to vaccinate. It focuses on recommended childhood vaccines but is also applicable to discussions with other groups recommended for vaccination. We propose categories or positions that reflect different parental attitudes and behaviours regarding vaccination and suggest specific communication strategies tailored to each position. The overarching goal of the encounter is to promote quality decisions and, ultimately, vaccination.
Development of the framework
The framework was developed to:
a) be acceptable to health professionals
b) increase health professional and parent satisfaction with discussions about vaccination
c) increase health professional’s self-efficacy (sense of confidence and competence) in relation to communicating about vaccination
d) increase the likelihood of the parent making a decision based on evidence (by increasing access to quality information)
e) encourage uptake of recommended vaccines.
There were three stages in developing the framework: a literature review, classifying parental positions on vaccination, and matching strategies to these positions …
Table 2 Parental positions on vaccination according to attitudes and behaviours
Unquestioning acceptor 30–40%
These parents vaccinate or want to vaccinate their children and have no specific questions about the safety and necessity of vaccines. In Gust’s study, they corresponded with the immunisation advocates or go along to get along groups who see the importance of childhood vaccination and are confident in its safety . They report a good relationship with their healthcare provider and agree that medical professionals have their child.s best interests at heart. This group tend to have less detailed knowledge about vaccination [29,30].
Cautious acceptor 25–35%
These parents vaccinate their children despite minor concerns. They may exhibit a hope and pray mentality recognising that vaccines carry rare but serious side effects and hoping that their child is not affected . Both this category and unquestioning acceptors were drawn from Benin’s category of vaccination acceptors .
The hesitant 20–30%
These parents vaccinate their child but have significant concerns . In Gust’s study, they most closely correspond to the fence-sitter who only slightly agrees about the benefits and safety of vaccination and is neutral about their relationship and trust with their healthcare provider . Hesitants are also more focused towards vaccine risk, and are aware of issues surrounding the MMR vaccine and of other parents not vaccinating their children . Trust in their doctor or nurse is key for this group who are keen to have discussions in which their questions are answered satisfactorily and completely by knowledgeable health professionals with relevant information .
Late or selective vaccinator 2–27%
Concerns about vaccination result in this group choosing to delay or select only some recommended vaccines . This group most closely correspond with Gust’s worried category with significant doubts about the safety and some doubt about the necessity of vaccines . They have concerns about the number of vaccines children have . They experience conflicting feelings about how to get their questions answered and who to trust,  and are similar to the vaccine hesitant in actively seeking information [29,46]. Probably because they actively seek information, in Benin’s study they had the highest levels of knowledge about vaccination  and prefer statistical arguments to anecdotal information . With a specific vaccine scare more parents may selectout the vaccine, as was the case with MMR vaccine in the UK .
Parents in this group refuse all vaccines for their child. This results from either their existing philosophical position on vaccination, negative experiences with the medical system, or religious beliefs . Contact with the medical establishment and doctors often results in feelings of alienation and disenchantment and they tend to prefer the advice of alternative health professionals [29,41]. Respondents in Benin’s study indicated a desire for a doctor with whom they could enjoy a trusting relationship and who would accept their decisions about vaccination. Benin’s sample of 33 mothers had less accurate knowledge about vaccination than all other groups except acceptors . These parents tend to cluster in communities who share certain religious, philosophical or alternative beliefs .
Table 4 Example of dialogue with the unquestioning or cautious acceptor parent
Health professional: Hello Mrs Cheung. I understand you have brought Lily for her vaccinations today.
Mother: Yeah, that’s right.
Health professional: Hello, Lily. OK, have you read the leaflet about the injections? I’d be happy to share with you more information about vaccination. (build rapport, seek questions and concerns)
Mother: Well only one thing. She had a slight cold last week, she seems to be over it now but I just wondered if it was safe.
Health professional: She’s back to her normal self now?
Mother: Yes she is.
Health professional: Then it is safe for Lily to have them today. (pausing to allow mother to interject if she has questions and observing body language) We are vaccinating her against measles, mumps and rubella, Hib, meningococcal C
disease and pneumococcal disease* – all serious diseases which have been made much rarer through vaccination programs. It will be three injections and I will give her two in one arm and one in the other arm. They may upset her for a few moments but most children settle straight away after some comforting and 90% don’t have any other side effects at all (positive framing of risk using percentages). If there is a problem, the commonest thing is a slightly sore arm that will last for a few days and then settles (pause to allow questions or clarification – chunking and checking).
Mother: OK – anything else?
One of the vaccines contains a small amount of weakened measles, mumps and rubella viruses which stimulate Lily.s immune system to respond and develop protection to these infections. That means she may have some mild symptoms of measles, such as a rash and a fever, and she may feel a bit offcolour 7 to 11 days after the vaccine. (pause) About 3 weeks after the vaccine, she may get a mild form of mumps, with swelling under her jaw. But this is less common and happens in only about 1% of children (qualitative and quantitative risk estimates). These symptoms are not infectious so she can’t pass them onto to anyone else and they usually go away after 1 to 2 days. The side-effects of the vaccine are usually mild and they are milder than the risks of having measles, mumps or rubella diseases. If you have worries afterwards, bring her back to the clinic and we can check her over. How does that sound? (structured information using chunks and checks and unbiased expectation of consent)
Mother: Fine, yeah, that.s OK.
* Based on UK vaccination schedule in 2011 
Table 5 Example of dialogue with the hesitant parent
Health professional: Good morning Mrs Wilkinson. I understand you have brought Robbie for his first infant vaccinations today.
Mother: That’s right.
Health professional: OK, have you read the leaflet about the injections? What questions are on your mind? (build rapport, seek questions and concerns)
Mother: Well, I’m pretty nervous – he seems so young.
Health professional: You sound quite worried (empathic response), let’s talk it through together, tell me what you are concerned about? (further building rapport and eliciting concerns)
Mother: One of the mums in my mothers. group said that one of the injections has got five ingredients and that’s too many for their immune systems to cope with. He does seem so young to be having injections against all these diseases at once. Won’t it make him ill?
OK, we can talk about this (guiding) but do you have other worries as well? (eliciting further concerns)
Mother: Well I read also that they can get a sore leg afterwards, so that’s another worry.
Health professional: (pausing to allow mother to interject if she has questions and to observe body language) Right, let’s talk about the five ingredients and then we can talk about the chances of getting a sore leg (signposting and structuring of explanation). You’re right that the injection has got five ingredients which would protect Robbie from the diseases called diphtheria, tetanus, whooping cough, polio and Haemophilus influenzae b (Hib). It seems a lot doesn’t it (empathic response). Children, even newborn babies, have to deal with
enormous amounts of bacteria and other foreign material every day, and the immune system responds to each of these in various ways to protect the body. Babies’ immune systems can handle this, and the vaccines these days are so refined that babies can easily cope with several vaccines in one go. (chunk of information provided followed by pause for mother to raise further questions and health professional to observe mother’s body language).
Mother: OK, and will he get a sore leg?
Health professional: Most children don’t have any reaction at all, other than having a cry with the injection, and even then they generally settle really quickly with a cuddle and some comforting words from mum (empowering). It’s true that a small number of children, about 10%, or 1 in 10, can get a redness or a sore area where the needle goes in (acknowledging) – but these reactions don’t usually distress the child, and only last a couple of days, then go away. So what I ask mothers to do is to watch their child and if they are concerned bring them back to the clinic so we can check them over. How does that sound? (avoid being overly persuasive, positive framing of risk)
Mother: Is there anything in particular I should watch for?
Health professional: Robbie may be a bit unsettled for a day or so after his injection but he shouldn’t be ill with it. The leaflet tells you about what to look out for and what to do if you are concerned.
Mother: Thanks – I’m still a bit nervous but I think we should get it done.
Table 6 Example of dialogue with the vaccine-refusing parent
There is a discussion about Oliver’s upper respiratory tract infection then:
Health professional: Do you mind if we take a moment to talk about Oliver’s vaccinations?
Mother: Ah, yes, we did some research into it and decided not to vaccinate him.
Health professional: OK, can I just talk it through so I understand your decision? (asking permission to discuss and use of a guiding style)
Mother: Yeah, OK.
Health professional: To start with can I just ask you how important you think it is to get Oliver protected from the diseases vaccines are designed to prevent? (assessing importance)
Mother: Well, mostly the diseases aren’t that much of a problem in healthy children and we keep Oliver very healthy with a good diet, organic food, and plenty of fresh air.
Health professional: You’re right, most children will overcome illnesses without too much of a problem (acknowledging). Unfortunately, there are still children that get pretty sick with these diseases, and sadly a significant number of children end up in hospital with complications from the disease. With measles, for example, 9 in every 100 children get pneumonia and some need to go to hospital (pause).
Mother: I didn’t know that.
Health professional: Yes, it can still be a serious problem. Could I ask now how confident you are that the vaccinations are safe? (assessing confidence)
Mother: I’m not all confident in them being safe.
Health professional: What have you heard? (exploring)
Mother: Well on one internet site it said that children can get brain damage and all kinds of problems after vaccination. And the drug companies try to cover it up.
That sounds frightening (empathic response). Which vaccines are you most concerned about? (eliciting specific concerns)
Mother: The MMR one because it can cause autism.
Health professional: I understand you are concerned about vaccinations (building rapport by accepting rather than rebutting concerns) but I’d just like to give you my view if that.s OK? (Mother nods.) Although there has been some research that raises concerns about vaccine safety, each time a concern comes up, new research is done to check whether the results are consistent or not. The
vaccines that we use are very safe and serious side effects are very rare. Would you like to look at the MMR vaccine decision aid which can help you weigh up the risks of the vaccine and the diseases? (respecting autonomy, offering information)
Mother: Well, I guess I could have a look but I’m still pretty cautious about Oliver
getting these jabs.
Health professional: Well, take a look at the decision aid and then if you like, come back to the clinic for another talk. We have a clinic each Tuesday and I’ll be here most weeks. Would you like to come back in two weeks? (leaving door open to further discussion)
Mother: OK thanks.