To be able to approach the vaccine-hesitant parents more effectively, it is crucial that the health care workers first appreciate the reason behind the development of parents' ambivalence towards immunization (MacDonald & Finlay, 2013). As well, Luthy, Beckstrand, & Callister (2010) explained that it is important for health providers to first understand the parents' perspectives towards immunizations after which they should respond to the concerns and questions raised based on evidence-based data.

The exposure that the parents have had with purported 'experts' keen on making cognitive shortcuts, using flawed logic and sending mixed messages play a part in parental confusion regarding vaccine safety (MacDonald & Finlay, 2013). According to Diekema (2012), misleading or false information about vaccination tends to result from a few influential individuals, describing themselves as vaccine-safety advocates, with some clinicians. Then, their messages are widely dispersed by the susceptible population (Diekema, 2012).

There is a likelihood for parents to easily recall a friend's or media story claiming about the negative side effects of a vaccine even when they have never witnessed such. The traditional media, Internet and celebrities also play a part in encouraging vaccine refusal. The anti-vaccine messages tend to have a significant impact such that even five to ten minutes on an anti-vaccine website are adequate to dramatically convince and alter the perception that a parent has regarding a vaccine, contributing to vaccine refusal.

Anti-vaccine messages are filled with cognitive errors in reasoning and distortion of reality, their messages tend to be powerful to a level that they frequently linger in the parents' subconscious, thus influencing their decision-making (MacDonald & Finlay, 2013).

Back

Three of the most common myths presented by parents include an alleged link between autism and vaccines, overwhelming the immune system with the administration of multiple vaccinations, and the inclusion of thimerasol increasing the level of mercury leading to autism. Provide adequate reading material or educational resources for parents to review at home (Healy et al., 2011)

Explain the importance of herd immunity, societal benefits and discuss the impact that lower herd immunity would have. Address common myths surrounding vaccinations and discredit them by providing factual information.

Relevant interventions are those that increase the awareness that the parents have regarding the logistical and practical factors linked to vaccination or aim at enabling them to understand the relevance and meaning of vaccination not only for themselves but also for their family and community (Kaufman et al., 2013).

Provide immunization timelines and schedules. This enables parents to feel more responsibility, have greater involvement and more control over the care of their children. (Awadh, et al., 2014)

Back

Hendrix, et al. (2014) acknowledges studies that have observed that effectively communicating the benefits of vaccines has a positive effect in increasing the likelihood of adults adhering to vaccinations for themselves. Numerous studies have evidenced instances where efforts to underscore herd immunity as a vaccine benefit have played a part in improving their willingness of vaccinating oneself. Several explanations have been proposed for this effect such as leveraging the sense of social responsibility that people to vaccinate themselves for the greater societal good, particularly to benefit those with compromised immune systems or those that cannot be vaccinated. The concern, however, relates to whether it is possible for such messaging approach to be effective in the case of parents making decisions over the immunization of their children. This is considering the evidence indicating that surrogate decision-making tends to differ from a situation where an individual is making decision for oneself (Hendrix, et al., 2014).

Kaufman et al (2013) performed a randomized controlled trial where they assessed the effectiveness of face-to-face interventions for informing or educating parents about early childhood vaccination. Their study contained 6 RCTs and 2978 participants. The studies suggest that face-to-face strategies do not consistently improve immunization rates or parent knowledge and understanding of vaccination, but the evidence was low to very low quality for these outcomes. Only one study measured the cost of a face-to-face case management strategy. The results of the study had limitations due to the fact that there were small numbers of included studies and outcomes measured.

According to Luthy, Beckstrand, & Callister (2010), dismissing the concerns that vaccine hesitant parents have towards immunization may play a part in fostering further negative attitudes toward childhood immunizations. Thus, it is critical that an honest and direct line of communication is established about the same. Luthy, Beckstrand, & Callister (2010) observe the existence of a correlation between childhood immunization rates and an honest and direct communication about immunization benefits and risks with parents. Furthermore, the recognition and addressing of parental concerns assist in preventing further erosion to childhood immunization rates.

Back

A crucial aspect that Luthy, Beckstrand, & Callister (2010) acknowledge is that there is a likelihood of parents to not trust information provided by government agencies. However, they observe that parents having questions relating to immunization safety have been observed to report their trust in the opinions of their family physicians relating to immunization, particularly when the providers listen and respond to their concerns. Thus, as they are more well-positioned as the main provider of health care services, family physicians are likely to be in an opportune position in sharing their opinions on immunization safety and promoting childhood vaccination (Luthy, Beckstrand, & Callister, 2010).

Diekema (2012) acknowledges the effectiveness in using persuasion techniques. Hereby, persuasion does not only require a reasonable argument. The messenger needs to not only be trustworthy but also attentive to the audience while being able to engage the audience emotionally. Facts and data, however supportive they are to vaccination, are likely to be insufficient in competing with the emotional appeals against vaccination. Rather, using a compelling story regarding a victim of an illness that can be prevented by vaccination is likely to be more effective in moving an audience to action.

The graph below represents the results of a study performed by Gust et al (2007) after completing 3,924 interviews with parents. The results show the main reasons why parents who planned to delay or not receive a vaccine for their child changed their minds.

Back

Despite efforts by providers to adhere to appropriate immunization practices, obstacles to patients being vaccinated may exist within the practice setting, unknown to the provider. These barriers to immunization may be physical or psychological (Wortley, 2012)

Physical barriers are aspects such as inconvenient clinic hours for working parents, or long waits at the clinic. Family physicians need to determine the needs of their specific community and take steps, such as extending clinic hours (Wortley, 2012)

Psychological barriers to healthcare are often more subtle but are just as important. Unpleasant experiences such as fear of immunizations, or being criticized for previously missed appointments, may lead parents to postpone receiving needed vaccinations (Wortley, 2012)

Back

There is strong scientific evidence and governmental support for the use of reminder and recall systems to improve immunization coverage rates. The Center of Disease Control (CDC) strongly advocates the use of reminders for both parent and providers. As stated earlier many parents are unaware their child is not fully vaccinated, thus it is beneficial for parents to have the next immunization appointment in hand before leaving the provider.

One strategy suggested by the CDC is to link the return visit to an upcoming holiday or the child's birthday. Even with written schedules, recall messages to parents alerting them that immunizations are due soon or past due is an effective tool in increasing attendance rates.

Reminder and recall messages to parents can be issued through many forms of communication including phones calls, letters, and automated systems. The CDC also encourages providers to create reminder and recall systems within their practice in order improve overall-awareness, and avoid missed opportunities. Similar to reminders for parents, reminder systems for providers can be done at low cost, though the use of simple protocols. One simple but effective strategy suggested is the utilization of an immunization stamp or clip that can be attached to a patient chart indicating that immunizations are due soon or past due.

In their systematic review, Williams, Woodward, Majeed, & Saxena (2011) focused on various kinds of interventions that can be considered to improve vaccination among the hesitant parents. One category involves the client-based interventions that target parents and children to raise the demand for immunization services. By educating communities, particularly parents, about the benefits that would arise in vaccinating their children is capable of empowering parents to embrace preventive health care, thus, improving their immunization uptake. The first approach that they consider in this category relates to reminders and recalls. These approaches are aimed at advising parents regarding impending vaccinations and remind parents whose children are overdue. There is a range of methodologies that can be applied with some including generic postcards, automated telephone calls, home visits and personalized letters. Impressively, adopting parental reminders has been found to positively affect immunization uptake generally.

Apart from the client-based interventions, Williams, et al. (2011) covers another category involving provider-based interventions aimed at improving the vaccination rates through the reduction of opportunities where medical professionals miss to immunize children. The first approach in this category includes provide reminder or recall in which the client's immunization status is investigated either manually through note searching or automatically by computer notifications. Afterwards, providers are notified through paper or computer-based prompts that there is a due or overdue vaccination.

Encouragingly, Williams, et al. (2011) observe that electronic reminders and manual searching have demonstrated positive effects on immunization rates. The second approach in this category involves provider education aimed at enhancing the knowledge that the immunization providers have through a range of tools such as educational resources and peer support. However, an evidenced based conclusion could not be made due to the limited attention that has been specifically focused on this strategy (Williams, et al., 2011). Furthermore, feedback approach emerges as another strategy that can be utilized. This involves retrospective evaluation of providers in any childhood immunization campaign or program and feeding this information back to the medical practitioner. This strategy can be combined with various other strategies such as provider education and financial incentives (Williams, et al., 2011).

Back

Addressing the issue surrounding pain that can be experienced when receiving a vaccine can pose both physical and psychological barriers. In a review analyzing the success of The Immun-wize Project, Miner, Faux, Sperhac, and Luthy explain the influence of child anxiety in the delay and refusal of early childhood vaccinations. The Immun-wize Project was launched in the state of Utah in 2006 to combat the states disproportionately low vaccination rate. According to Luthy et al (2010), the influence of a child's pain, crying, or anxiety on parents unwillingness to immunize their children on time should not be overlooked.

Children who experience intense feelings of anxiety both before and during immunizations may increase anxiety for the parents, which may in turn promote parental procrastination of future immunizations (Luthy, et al., 2014). Luthy et al (2010) encourage providers to educate parents on how to help relieve their child's anxiety before and during immunizations. A handout including tips for parents during an immunization visit could be distributed to parents during clinic visits or made available on the clinic's website (Luthy, et al., 2014).

The "Clinical Practice Guideline: Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline" adapted from CMAJ introduced the 4 P's of pain management during vaccine injections. The pharmacological approach included the use of topical anesthetics ie lidocaine or tetracaine. The physical approach described the importance of holding a child in a protective manner and the evidence of breastfeeding prior to, during and after the injection is administered. The psychological component included the importance of breathing deeply and distraction ie cuddling, singing, talking, rocking. Finally, the procedural component discussed rapid intramuscular injection with no aspiration and if multiple injections are to be given, to administer the most painful once last.

Back

There are some physicians seeking for a firm stance against outright refusal or alternative schedules with the aim of protecting their patients and preventing what they consider to be creeping towards increased vaccine hesitancy. Whereas, there are those that argue that vaccine refusal entails medical neglect and accommodating refusal is likely to leave them vulnerable to liability in case of outbreaks arising from intentional non-vaccination (Buttenheim, Cherng, & Asch, 2013).

Of particular attention has been the tendency of those physicians dismissing families for refusing vaccination as this raises a series of ethical, legal and public health considerations. Dismissing a family due to vaccine refusal needs to raise concerns regarding the liability for negligence, which can spark their regulatory body to take action against them. It is the duty of a physician to treat a patient once they form a physician-patient relationship, unless the patient is provided with a reasonable notice of dismissal or has been transferred successfully to another care provider (Halperin, Melnychuk, Downie, & MacDonald, 2007).

Back

Eliminating exemptions based on religious or personal beliefs may appear logical, but substantial resistance is likely to arise against such effort and can even ignite anti-vaccination sentiments. One of the approaches that can be adopted to improve immunization is through altering the ease in which parents can obtain exemption and enforcement of the school-entry entry requirements. The exemption process ought not to be a less costly or easier process in comparison to the vaccination process.

One seeking to obtain a personal or religious-belief exemption should be required to at least physically visit a physician's office to be counselled about the risks posed by un-vaccination and insurance ought to pay for those visits. Furthermore, exemption requests can be required to be signed by both parents. While agreeing that even tough measures may not succeed in changing the stance of the very hesitant parents, they would effectively eliminate numerous exemptions that are mainly sought based on convenience rather than religious and personal conviction.

Having lax enforcement sends the message that vaccination is just a mere bureaucratic requirement and not mechanism to ensure students' safety and a prerequisite for school attendance (Diekema, 2012).

An example of a refusal to vaccinate form is provided by the American Academy of Paediatrics and can be found within the handout section.

Back