Provider dismissal of vaccine-hesitant families: misguided policy that fails to benefit children

Conflicting and complementary notions of responsibility in caregiver's and health care workers' vaccination narratives in the Philippines

Background

Vaccine hesitancy (VH) continues to pose a public health threat globally. Understanding the attitudes and perceptions about vaccination of key stakeholders in vaccine decision-making (such as health care workers (HCWs) and caregivers) about vaccination can pave the way toward novel approaches to bolster vaccine confidence. In this study, we explored the role of notions of responsibilities among HCWs and caregivers in shaping vaccination interactions and decision-making in the Philippines.

Methods

We conducted in-depth interviews (IDIs) and focus group discussions (FGDs) with 44 vaccine-hesitant caregivers, seven HCWs, and 20 community health workers (barangay health workers) in the Philippines between August 2020 and March 2021. The interviews and focus groups were conducted online, transcribed verbatim, and analysed through the reflexive thematic analysis approach.

Results

Caregivers highlighted responsibility in terms of being a good caregiver, managing risk to one's own child, and seeking and validating information. Meanwhile, HCWs highlighted responsibility as: being a good HCW, managing risk to children and to the community, and providing and transforming information. Our findings suggest that responsibility manifests differently in HCWs' and caregivers' narratives, and that these notions can be both conflicting and complementary, shaping the interaction between stakeholders and, ultimately, their vaccine decision-making. We also found that fostering a good relationship between HCWs and caregivers through communication techniques such as motivational interviewing could help bridge the gap created by mistrust in vaccinations. HCWs sharing their own experiences as parents who vaccinate their own children also resonate with caregivers.

Conclusions

Notions of responsibility can underpin collaborative and divisive interactions between HCWs and caregivers. Public health messaging and interventions related to vaccination must consider strategies that align with these notions to address VH.

Vaccine Hesitancy in Pediatrics

Vaccine hesitancy is a growing complex and multifaceted phenomenon. It encompasses a wide spectrum of context-dependent attitudes and beliefs. Multiple factors influence parental decision-making including knowledge, sources of information, risk perception, trust, and individual experiences among others. This review focuses on describing the most common reasons that contribute to vaccine hesitancy among parents. Social media and the Internet have been described as major elements that can negatively influence parental decision-making regarding vaccines. The next focus is describing effective interventions that clinical providers can apply. Nonconfrontational and open discussions along with trusting and strong relationships between parents and providers seem to create a solid foundation toward vaccine acceptance. In addition, motivational interviewing is a helpful tool that has proven to be effective during these discussions. Ultimately, an individualized approach tailored to a specific community will likely be most effective in addressing vaccine hesitancy.

The problem of vaccination refusal: a review with guidance for pediatricians

PURPOSE OF REVIEW

In the wake of multiple recent outbreaks of the measles and other vaccine-preventable diseases, it is crucial to understand and address parental concerns about vaccination. The purposes of this review are: to identify the causes of vaccine resistance, to elucidate the variables that have led to the success or failure of interventions to date, and to consider implications for pediatricians treating children whose parents are vaccination-resistant.

RECENT FINDINGS

Recent research draws on insights from cognitive science to understand vaccine resistance and to develop more effective interventions. Studies show that vaccine resistors are more likely to value lifestyle liberty, to favor individualistic over hierarchical worldviews, and to believe in conspiracy theories. Interventions that seek primarily to correct erroneous beliefs about the dangers of vaccination are likely to fail or even backfire. On the other hand, intervention strategies, such as motivational interviewing, in which the provider elicits and shows respect for parents' values and concerns while empowering them to make well informed and well reasoned decisions, are more likely to be successful. Parents cite a trusting relationship with their pediatrician as the most important factor influencing their decision to vaccinate.

SUMMARY

Pediatricians are in the best position to successfully apply insights from cognitive science and intervention research to overcome vaccination-hesitancy.

Dismissal policies for vaccine refusal among US physicians: a literature review

Childhood vaccination is one of the greatest public health achievements of the 20th century, yet increasingly, parents question the safety of and need for vaccines. This has led to increased rates of vaccine delay and refusal and outbreaks of vaccine-preventable diseases. Physicians struggle with how to respond to families who refuse vaccines, as there are few known effective interventions to convince a family to vaccinate. In the United States, the practice of dismissing families for vaccine refusal appears to be increasing as a strategy for dealing with vaccine refusal. In this review, we review the literature surrounding this controversial practice, starting with the impact that vaccine-refusing families have on medical practices, followed by a review of dismissal policies of US physicians, and ending with a discussion of the ethics of this practice.

Nurses' Perceptions Of MMR Vaccine Hesitancy In An Area With Low Vaccination Coverage

BACKGROUND AND AIM

Measles, mumps, and rubella vaccine (MMR) coverage is low in an area in the Northern part of Stockholm, Sweden. The overall aim of this study was to explore the perceptions, views, and experiences of child health clinic nurses related to vaccine hesitancy in Rinkeby and Tensta.

METHODS

The study focused specifically on hesitancy towards measles-mumps-rubella (MMR) vaccination. Eleven in-depth interviews were conducted in Swedish with female nurses who were directly responsible for vaccination programmes. Their thoughts and experiences were sought using probing and question rephrasing techniques. Transcripts of the data were analysed using content analysis.

RESULTS

Four themes emerged, namely hesitancy among Somali parents, lack of confidence in the MMR vaccine, loss of confidence in other vaccines due to mistrust of the MMR vaccine, and complacency regarding vaccination in general.

CONCLUSION

There is a strong influence of fear of vaccine-induced autism among parents in the Somali community in areas of Stockholm, that requires continued attention by the health care providers.

Addressing vaccine hesitancy: Clinical guidance for primary care physicians working with parents

OBJECTIVE

To provide primary care physicians with clinical guidance for addressing parental vaccine hesitancy.

SOURCES OF INFORMATION

The PubMed database was searched for English-language articles published in the 10 years before January 1, 2018. Search terms included vaccine hesitancy or confidence or acceptance, parents or children, and communication, counseling, or clinical practice. References of identified articles were assessed for additional relevant articles. A separate gray literature search was conducted using Google to find best-practice guidelines from public health and health care organizations, knowledge translation materials for health care providers, and resources that could be used in discussions with parents about vaccines.

MAIN MESSAGE

Practical tips for addressing parental vaccine hesitancy in primary care include starting early, presenting vaccination as the default approach, building trust, being honest about side effects, providing reassurance on a robust vaccine safety system, focusing on protection of the child and community, telling stories, and addressing pain. Also provided are statements that providers could use in vaccination-related conversations; answers to commonly asked questions on benefits, safety, and immunologic aspects of vaccines; and links to a number of online resources for physicians and parents.

CONCLUSION

Vaccine-hesitant parents who are on the fence far outnumber vaccine refusers; therefore, counseling this group might be more effective. Reasons behind vaccine hesitancy are complex and encompass more than just a knowledge deficit. As a trusted source of information on vaccines, family physicians play a key role in driving vaccine acceptance.

Répondre à l’hésitation face à la vaccination

Objectif

Conseiller aux médecins de première ligne une approche clinique pour parler de l’hésitation face à la vaccination avec les parents.

Sources de l’information

On a recherché sur PubMed des articles publiés en anglais dans les 10 années ayant précédé le 1er janvier 2018. Les mots-clés anglais étaient vaccine hesitancy ou confidence ou acceptance, parents ou children, et communication, counseling ou clinical practice . On a épluché les références des articles relevés, à la recherche d’autres articles pertinents. Une recherche distincte de la littérature parallèle a été effectuée sur Google pour trouver les lignes directrices de pratique clinique publiées par les organisations de santé publique et de soins de santé, le matériel de transfert des connaissances à l’intention des professionnels de la santé et les ressources pouvant être utilisées durant les conversations avec les parents sur les vaccins.

Message principal

Les conseils pratiques pour répondre à l’hésitation des parents face à la vaccination dans les soins de première ligne consistent à commencer tôt, à présenter la vaccination comme l’approche par défaut, à établir une relation de confiance, à être honnête quant aux effets secondaires, à rassurer les parents en leur disant que le système d’innocuité vaccinale est solide, à s’attarder sur la protection de l’enfant et de la collectivité, à raconter des histoires et à parler de la douleur. Nous fournissons aussi des énoncés que les professionnels de la santé peuvent utiliser durant les conversations sur les vaccins; des réponses aux questions souvent posées sur les bienfaits, l’innocuité et l’aspect immunologique des vaccins; et des liens vers un certain nombre de ressources en ligne à l’intention des médecins et des parents.

Conclusion

Les parents qui n’ont pas pris position quant aux vaccins pour leurs enfants sont beaucoup plus nombreux que les parents qui refusent les vaccins; il serait ainsi plus efficace de conseiller ce groupe de parents. Les raisons qui incitent à la réticence chez les parents sont complexes et comprennent plus qu’un simple manque d’information. À titre de sources fiables d’information sur les vaccins, les médecins de famille jouent un rôle de premier plan pour stimuler l’acceptation des vaccins.

Factors Associated With Pediatrician Responses to Alternative Immunization Schedule Requests

We conducted a cross-sectional online survey among 4 chapters of the American Academy of Pediatrics from July through October 2014 to describe characteristics of pediatricians and practices associated with practice-level responses to alternative immunization schedule requests. Among 374 pediatricians, 58% reported frequent alternative immunization schedule requests and 24% reported feeling comfortable using them. Pediatricians who work in practices that accommodate alternative immunization schedule requests have increased odds of having a high frequency of alternative immunization schedule requests, and beliefs that relationships with families would be negatively affected if they refused requests. Practices that discontinue care to families who request alternative immunization schedules have increased odds of being a private group practice and having a formal office vaccine policy. Pediatricians are frequently asked to use alternative immunization schedules and many are not comfortable using them. Practice-level responses to alternative immunization schedules are associated with characteristics of pediatricians and practices.

Countering Vaccine Hesitancy

Immunizations have led to a significant decrease in rates of vaccine-preventable diseases and have made a significant impact on the health of children. However, some parents express concerns about vaccine safety and the necessity of vaccines. The concerns of parents range from hesitancy about some immunizations to refusal of all vaccines. This clinical report provides information about addressing parental concerns about vaccination.

Ethics and Childhood Vaccination Policy in the United States

Childhood immunization involves a balance between parents' autonomy in deciding whether to immunize their children and the benefits to public health from mandating vaccines. Ethical concerns about pediatric vaccination span several public health domains, including those of policymakers, clinicians, and other professionals. In light of ongoing developments and debates, we discuss several key ethical issues concerning childhood immunization in the United States and describe how they affect policy development and clinical practice. We focus on ethical considerations pertaining to herd immunity as a community good, vaccine communication, dismissal of vaccine-refusing families from practice, and vaccine mandates. Clinicians and policymakers need to consider the nature and timing of vaccine-related discussions and invoke deliberative approaches to policy-making.

Characteristics of Physicians Who Dismiss Families for Refusing Vaccines

BACKGROUND AND OBJECTIVES

Physicians dismissing families who refuse vaccines from their practices is controversial. We assessed the following among pediatricians (Peds) and family physicians (FPs): (1) reported prevalence of parental refusal of 1 or more vaccines in the infant series; (2) physician response to refusal; and (3) the association between often/always dismissing families and provider/practice characteristics and state exemption laws.

METHODS

Nationally representative survey conducted June to October 2012. A multivariable analysis assessed association of often/always dismissing families with physician/practice characteristics, state philosophical exemption policy, and degree of difficulty obtaining nonmedical exemptions.

RESULTS

The response rate was 66% (534/815). Overall, 83% of physicians reported that in a typical month, ≥1% of parents refused 1 or more infant vaccines, and 20% reported that >5% of parents refused. Fifty-one percent reported always/often requiring parents to sign a form if they refused (Peds 64%, FP 29%, P < .0001); 21% of Peds and 4% of FPs reported always/often dismissing families if they refused ≥1 vaccine. Peds only were further analyzed because few FPs dismissed families. Peds who dismissed families were more likely to be in private practice (adjusted odds ratio [aOR] 4.90, 95% confidence interval [CI] 1.40-17.19), from the South (aOR 4.07, 95% CI 1.08-15.31), and reside in a state without a philosophical exemption law (aOR 3.70, 95% CI 1.74-7.85).

CONCLUSIONS

Almost all physicians encounter parents who refuse infant vaccines. One-fifth of Peds report dismissing families who refuse, but there is substantial variation in this practice. Given the frequency of dismissal, the impact of this practice on vaccine refusers and on pediatric practices should be studied.

Vaccine hesitancy: clarifying a theoretical framework for an ambiguous notion

Today, according to many public health experts, public confidence in vaccines is waning. The term "vaccine hesitancy" (VH) is increasingly used to describe the spread of such vaccine reluctance. But VH is an ambiguous notion and its theoretical background appears uncertain. To clarify this concept, we first review the current definitions of VH in the public health literature and examine its most prominent characteristics. VH has been defined as a set of beliefs, attitudes, or behaviours, or some combination of them, shared by a large and heterogeneous portion of the population and including people who exhibit reluctant conformism (they may either decline a vaccine, delay it or accept it despite their doubts) and vaccine-specific behaviours. Secondly, we underline some of the ambiguities of this notion and argue that it is more a catchall category than a real concept. We also call into question the usefulness of understanding VH as an intermediate position along a continuum ranging from anti-vaccine to pro-vaccine attitudes, and we discuss its qualification as a belief, attitude or behaviour. Thirdly, we propose a theoretical framework, based on previous literature and taking into account some major structural features of contemporary societies, that considers VH as a kind of decision-making process that depends on people's level of commitment to healthism/risk culture and on their level of confidence in the health authorities and mainstream medicine.

Vaccine hesitancy: clarifying a theoretical framework for an ambiguous notion

Today, according to many public health experts, public confidence in vaccines is waning. The term "vaccine hesitancy" (VH) is increasingly used to describe the spread of such vaccine reluctance. But VH is an ambiguous notion and its theoretical background appears uncertain. To clarify this concept, we first review the current definitions of VH in the public health literature and examine its most prominent characteristics. VH has been defined as a set of beliefs, attitudes, or behaviours, or some combination of them, shared by a large and heterogeneous portion of the population and including people who exhibit reluctant conformism (they may either decline a vaccine, delay it or accept it despite their doubts) and vaccine-specific behaviours. Secondly, we underline some of the ambiguities of this notion and argue that it is more a catchall category than a real concept. We also call into question the usefulness of understanding VH as an intermediate position along a continuum ranging from anti-vaccine to pro-vaccine attitudes, and we discuss its qualification as a belief, attitude or behaviour. Thirdly, we propose a theoretical framework, based on previous literature and taking into account some major structural features of contemporary societies, that considers VH as a kind of decision-making process that depends on people's level of commitment to healthism/risk culture and on their level of confidence in the health authorities and mainstream medicine.

What are the factors that contribute to parental vaccine-hesitancy and what can we do about it?

Parental refusal or delay of childhood vaccines is increasing. Barriers to vaccination among this population have been described, yet less is known regarding motivating factors. Researchers are beginning to evaluate various approaches to address the concerns of "vaccine-hesitant" parents, but few studies have evaluated the effect of interventions on timely vaccine uptake. Several models for communicating with vaccine-hesitant parents have been reported for healthcare providers; however, the effectiveness and utility of these strategies has not been quantified. This article reviews the known barriers to vaccination reported by vaccine-hesitant parents and the current evidence on strategies to address parental vaccine hesitancy.

Caregivers who refuse preventive care for their children: the relationship between immunization and topical fluoride refusal

OBJECTIVES

The aim of this study was to examine caregivers' refusal of preventive medical and dental care for children.

METHODS

Prevalence rates of topical fluoride refusal based on dental records and caregiver self-reports were estimated for children treated in 3 dental clinics in Washington State. A 60-item survey was administered to 1024 caregivers to evaluate the association between immunization and topical fluoride refusal. Modified Poisson regression models were used to estimate prevalence rate ratios (PRRs).

RESULTS

The prevalence of topical fluoride refusal was 4.9% according to dental records and 12.7% according to caregiver self-reports. The rate of immunization refusal was 27.4%. In the regression models, immunization refusal was significantly associated with topical fluoride refusal (dental record PRR = 1.61; 95% confidence interval [CI] = 1.32, 1.96; P < .001; caregiver self-report PRR = 6.20; 95% CI = 3.21, 11.98; P < .001). Caregivers younger than 35 years were significantly more likely than older caregivers to refuse both immunizations and topical fluoride (P < .05).

CONCLUSIONS

Caregiver refusal of immunizations is associated with topical fluoride refusal. Future research should identify the behavioral and social factors related to caregiver refusal of preventive care with the goal of developing multidisciplinary strategies to help caregivers make optimal preventive care decisions for children.

Perceptions of personal belief vaccine exemption policy: a survey of Arizona vaccine providers

BACKGROUND

As exemptions to school-entry requirements rise, vaccination rates in Arizona school children are approaching levels that may threaten public health. Understanding the interactions physicians have with vaccine-hesitant parents, as well as the opinions physicians hold regarding vaccination, exemption, and exemption policies, are critical to our understanding of, and ability to affect, vaccination exemption rates among children.

METHODS

Survey responses were elicited from practitioners listed in The Arizona Partnership for Immunization and the Arizona Medical Association databases using a multi-pronged recruitment approach. Respondents provided data regarding their practice, comfort with parental refusal of individual vaccines, opinions about the beliefs held by parents that seek exemptions, parent education strategies, issues regarding providing care to unvaccinated children, and potential changes to Arizona policy.

RESULTS

A total of 152 practitioners providing care to a wide geographic and economic population of Arizona responded to the survey. Respondents were generally strong advocates of all immunizations but were more accepting of parents' desires to refuse hepatitis B and rotavirus vaccines. Almost all providers indicated that they see patients whose parents request to refuse or delay from vaccinations at least occasionally (88% and 97%, respectively). Only 37% of respondents indicated that they would be supportive of a policy requiring them to sign off on a parent's decision to refuse vaccination.

CONCLUSIONS

Vaccination providers in Arizona are generally very supportive of childhood immunizations but have varying comfort with exemption from individual vaccines. Responding providers tended to not support a requirement for a physician's signature for vaccine exemptions due to varying concerns regarding the implementation of such a practice.