Talking with parents who are declining

Talking with parents who are declining

Declining parents have never vaccinated or have stopped vaccinating their children altogether. Not all parents who have concerns about the safety or efficacy of vaccines intend to decline them completely. Ask if you are unsure.

The goals for a consultation with a declining parent are:

  • to maintain trust and engagement
  • to keep the consultation brief
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How to recognise parents who are declining

Declining parents: 

  • may not want to discuss vaccination at all
  • may present for other reason or medical exemption
  • may believe Vaccine Preventable Diseases (VPDs) are benign or beneficial
  • may distrust ‘big pharma’ and conventional medicine
  • may be more likely to seek complementary and alternative medicine
  • may have had a bad experience such as an Adverse Event Following Immunisation (AEFI) or a birth trauma, and be intent on getting the ‘right’ information  
  • may have alternative lifestyle approaches and feel that conventional medical treatments do not align with their personal values
  • may have a general sense of vigilance and a sense of responsibility around making the ‘right’ decision.

Tips for consultations with parents who are declining

Consultations with these parents can be kept short. Declining parents have made their decisions and will resist attempts to persuade them to vaccinate their children. Engaging declining parents in debate about the validity of their beliefs can result in extended, unproductive consultations and should be avoided; it can increase their risk of disengaging from the health care system altogether. 

The process we recommend below has been designed to expedite consultations and minimize harm to the child by preventing parental disengagement.

< Elicit

Seek permission to discuss

“The nurse mentioned she hasn’t had her 6 week vaccinations. Do you mind if we discuss that?”

Most parents of under-vaccinated children have not made an active decision to decline. It is important to confirm whether this was an active choice or an unintended situation. This  gives the parent the choice about having a discussion. Choice can be a strongly held value among non-vaccinating parents. 

(if agree to discuss) Elicit reasons for decision

“Can you tell me what led you to your decision?”

“I'd like to understand your decision. Can you tell why you’ve decided not to vaccinate George?”

Open questions elicit information more efficiently than questions that can be answered by one or two words. Hearing all the reasons for the person’s decision can help the clinician set out the options available and plan more collaboratively. 

Resist the righting reflex

“Can you tell me more about that?” 

The temptation to correct misconceptions is powerful but psychological evidence suggests it can actually reinforce or strengthen mistaken ideas7 and establish an adversarial climate3. Correcting misinformation before a parent has had the chance to express all of their concerns or ask all of their questions tends to close down the conversation. Parents may perceive this as adversarial and feel the need to defend themselves. This can consume consultation time that might otherwise be spent more productively.

< Offer to share knowledge about immunisation

Acknowledge parent

“I can see you have done a lot of thinking about this.”

A parent who feels acknowledged is more willing to hear your information. It can be difficult to offer acknowledgement to a parent who is expressing ideas you disagree with or know to be false. Acknowledging a parent’s effort or intent does not require you to agree with the subject of their questions or concerns2. This kind of acknowledgement signals respect for the parent and builds their trust in you3. This can help you avoid the righting reflex (see Resist the righting reflex above).

Explore motivations to reconsider

“Are there any diseases you are worried about Linn getting?”

“Is there something that might make you reconsider vaccinating Maya in future?”

“Would you consider vaccinating Stefan if there’s an outbreak in our community or you’re planning travel?”

“When do you think Ariel will be old enough to be vaccinated?”

“Infectious disease can be mild, but I have also seen children who are very ill with them. Can I tell you about my experiences treating children who were admitted to hospital with an infectious disease.”

Some parents think about vaccination again when the risk of infection changes, such as when they plan to travel, or there’s an outbreak, or just when their child is a bit older. Some parents believe that vaccine-preventable diseases (VPDs) are always mild, self-limiting illnesses, or even that infectious diseases are beneficial. Hence, learning the parents’ views and potential concerns can help you more effectively lay out the options and collaborate on a plan. 

Share your recommendation

“Can I tell you why I recommend vaccination”?

“Would you be willing to consider just one vaccine today?”

Even if the parent isn’t ready to vaccinate, making your position clear is important. Moderating the language used can help. Presenting options tailored to the parent’s motivations and concerns is a more realistic starting point. 

Share "What should I look out for" resource

“I have some information about early signs of infectious diseases. Would you like to take it with you?”

“Has anyone showed you where to find information about government policies that affect families whose children aren’t fully vaccinated?”

Offering tailored information signals your attempts to listen to and understand the parent’s position. It expresses your continued willingness to provide medical care to the family and supports appropriate help-seeking. Maintaining engagement creates future opportunities to revisit the vaccination decision. Parents who experience negative or adversarial exchanges during consultations may become reluctant to seek medical care for their children at all. In one study, parents who declined vaccination made significantly fewer routine care visits than those who did not5.

< Plan and close

Offer opportunities to revisit

“Would you like to come back in [appropriate time frame] to discuss again? Meanwhile, would you like to take home [offer appropriate resource].”

“I’d be happy to talk with you about it again anytime.”

Assuring them that you will continue to treat the family minimises harm to the child and creates opportunities to revisit the vaccination decision.

Offer specialist referral if relevant

“It sounds like you’ve still got some questions. I can offer you a referral to a specialist service that can review his reaction and help you make a plan.”

Immunisation referral may be appropriate when parents have been put off by an adverse event following immunisation (AEFI). Learning that there is a system for assessing and planning following an AEFI may increase parents’ confidence in the system. Their complex questions and concerns can also be addressed6.

Resources
  1. Heritage J, et al. Reducing patients' unmet concerns in primary care: the difference one word can make. J Gen Intern Med 2007;22:1429-33.   https://doi.org/10.1007/s11606-007-0279-0   
  2. Silverman J, et al. Skills for communicating with parents 3rd. 2013; CRC Press: London, UK
  3. Berry, N, et al, When parents won’t vaccinate their children: a qualitative investigation of Australian primary care providers’ experiences. BMC Pediatrics. 2017; 17: 19 https://doi.org/10.1186/s12887-017-0783-2
  4. Opel DJ, et al. The influence of provider communication behaviors on parental vaccine acceptance and visit experience. American Journal of Public Health 2015;105:1998-2004. https://www.ncbi.nlm.nih.gov/pubmed/25790386
  5. Jones MU, Carter CG, Cameron KL, et al. The Impact of Vaccine Refusal on Physician Office Visits During the Subsequent 12 Months. Military medicine 2017;182:e1810-e15. https://doi.org/10.7205/MILMED-D-16-00442
  6. Berry, NJ, et al. Sharing knowledge about immunisation (SKAI): An exploration of parents’ communication needs to inform development of a clinical communication support intervention. Vaccine (In Press): https://doi.org/10.1016/j.vaccine.2017.10.077
  7. Cook, J & Lewandowsky, S, The Debunking Handbook. 2011 St. Lucia, Australia: University of Queensland. November 5. ISBN 978-0-646-56812-6. [http://sks.to/debunk

Other information for parents who are declining

Talking with parents who are declining