Well-educated, higher-income parents are more likely to be vaccine refusers-Vaccine Refusal by Parents on ADVANCE for NPs & PAs

Vaccine refusal by parents of infants and children presents a particular challenge to healthcare providers. The ability of vaccinations to decrease the incidence and prevalence of what once were common childhood illnesses has resulted in a population that has little firsthand knowledge or experience with the serious and deadly effects of diseases now prevented by immunization. At the same time, greater exposure to information from a variety of sources and personal interactions has contributed to suspicion and mistrust of immunization.1

The intent of this article is not to discuss the benefits and risks of vaccines; this information is readily accessible and based on years of empirical experience and scientific evidence. Instead, the article presents suggestions for working with parents who refuse to vaccinate their children. Suffice it to say that strong scientific evidence proves that the benefits of immunization substantially outweigh the risks. Therefore, it is the responsibility of all healthcare providers to promote the vaccination of patients in their care, especially the most vulnerable. A well thought out, rehearsed response and action plan to address vaccine refusal will assist providers in meeting this important challenge.1-4

It is imperative that NPs and PAs are knowledgeable and prepared to discuss all current recommendations and evidence-based practice literature on the subject of vaccinations. Furthermore, providers should stay informed about common vaccine-related parent concerns and refusal rationale, especially those stemming from past and current misconceptions often presented as fact in the media.

A Trusting Relationship

The first step in any patient-provider relationship is the establishment of trust built on mutual respect. When presenting any medical information, providers should keep in mind the characteristics unique to each family, such as health literacy, religion, socioeconomic status, cultural values and relationship supports. Parents who are considering or have already decided not to vaccinate are often concerned that providers do not value their opinion or listen to their concerns. It is essential that providers are cognizant of how their tone of voice and body language can reduce parent receptiveness and promote parent defensiveness and rigidity to medically sound information. If parents do not feel respected, they tend to be less receptive to the provider's advice. It is important that parents feel they are heard and that providers empathetically acknowledge parents' concerns.3-6

Identify and Address Issues

The most appropriate first response when a parent refuses to consent to vaccination, especially in the neonatal period, should feature one or two questions: "What is your concern about vaccination?" or "Why do you not want to have your child vaccinated?" These questions are open ended and require the parent to verbalize his or her concerns. The answer will provide insight into how to direct the conversation to best address the primary issue of concern for each family. The answer - and the parent's body language - can provide clues to the degree of motivation or interest in considering alternative vaccination views. A parent's response may suggest he or she is fearful that the child will be harmed or he or she has heard "bad stories" about vaccines from friends or relatives. This type of parent may only need reassurance and basic information about vaccine safety.3 Another parent might share detailed information, gathered from a website or friends, that supports his or her anti-vaccination position.

Well-educated, higher-income parents are more likely to be vaccine refusers.6,7 This type of parent requires a more thoughtful and prepared response - and a greater time investment. This type of parent may benefit from a "slow and soft approach" delivered over multiple appointments.1,3,5,7 It is vital that this first conversation end with a statement by the provider confirming that based on the scientific evidence, a commitment to immunization is the single best investment a parent can make for the health of his or her child and other children and adults in the community.

Some common reasons cited for vaccine refusal include: vaccines are unsafe (due to the actual biological agent or toxin introduction) and thus result in serious adverse events and chronic health problems; vaccines are not necessary today because diseases prevented by immunization are not serious; and that vaccines tax the immune system by exposing a child to too many antigens at once.1,3,5-7 Every provider who treats children should have an informed answer or "script," supported by scientific literature, to address each of these concerns. In addition, the provider should be prepared to supply parents with appropriate resource material (verbal, printed or web-based) that can be reviewed at home.5

A Vaccine Communication Model

One approach to vaccine communication, developed by Alison Singer, founder of the Autism Science Foundation, is called "Making the CASE for Vaccine Communication."8 This approach can be used by providers to address common reasons for vaccine refusal. A short video discussing the model can be found on the American Academy of Pediatrics website in the section on Immunization (see citation for url link).8

The CASE method uses empathy and common ground to begin conversations, progresses to the science and then concludes with advice to vaccinate.9 CASE is simple to remember, is proactive rather than reactive, and utilizes a conversational style to structure and guide an evidence-based discussion.

The CASE acronym reflects the four steps in the process: Corroborate, About me, Science and Explain. The provider acknowledges (corroborates) the parents' concern by finding some point of common ground, such as "I have also heard media reports about contaminated vaccines and I agree that it is concerning." In step 2, the provider relates what he or she has personally done (about me) to build on the parents' knowledge and expertise to address the concern they have in common. "I did a search of studies related to this, and I am confident, based on this information, that the vaccine supply is safe."

The next step is to build on the previous one by following up with the specifics (the provider's "script") that support the provider's conclusion (the science).

Finally, the provider should deliver advice (explain) in a direct, concrete and not easily misconstrued manner, supported by scientific evidence that immunization is in the best interest of the child and other children and adults in the general population.8

Depending on the direction the conversation takes and the style of the provider (how "soft and slow" he or she wishes to progress), some additional comments can be used to cement the conversation and explain the role vaccines play in the protection of the community.

Freeloading is a type of heuristic thinking in which parents refuse to vaccinate their child based on the theory that because other children get the vaccine, the risk to their child is not significant.1,4 In such a case, the provider can explain how refusal of vaccines perpetuates the possibility of renewed incidence and prevalence of the disease state itself, which history and science have proven causes more morbidity and mortality than any proven or disproven adverse vaccine consequence.

The provider should also reiterate to the parent that an unvaccinated child has a greater chance of contracting the disease. For example, the risk of measles is 35 times higher in exemptors even if they live in communities with herd immunity greater than 90%.10 As herd immunity decreases, vaccine-preventable diseases can spread to other children and adults who, because of medical conditions and immunosuppressed states, have an increased susceptibility to severe, possibly deadly outcomes related to the disease.

Providers can explain to parents that their decision to not vaccinate, combined with other parents who make the same choice, can have a direct impact on public health. An approach that can be used to illustrate the impact of immunization and public responsibility is to agree with the parent that the current risk of disease is significantly less than in the past, but to follow up with a reminder that the child's protection is only possible because millions of parents in previous generations chose to vaccinate their children.1,6

For parents who express concern about the cost of vaccination, assure them that vaccines are available at no cost or low cost and that every effort will be made to assist them to identify financial options. Parents should be educated that the disease states for most vaccine-preventable diseases are prolonged and severe (pertussis) and could result in lifelong disability and suffering (polio, mumps) - even death. These will require an investment of money and time away from other responsibilities to care for the ill child.

A Harsh Stance?

Some healthcare practices have established policies that they will not provide care to children whose parents refuse immunization. This is a drastic step that is ethically problematic because it may deny the child access to necessary medical care and will remove the opportunity to successfully revisit immunization at a later date.

Although universal immunization is strongly supported by the federal government and all medical associations, it is not legally required in federal law.1,5 State and school district requirements are highly variable. Vaccine refusal is a recognized condition (ICD code 464.05) and should be treated as such. Choosing not to vaccinate may impact the health of a patient and all people he or she comes in contact with. But it is unlikely that healthcare practices or organizations would attempt to exclude people who refuse flu shots. These people present a similar dilemma when they move about in the community or seek healthcare (infected patients waiting to be seen could communicate disease to healthy and immunocompromised people). As presented by the American Academy of Pediatrics Committee on Infectious Disease in its policy on disease transmission prevention in pediatric ambulatory settings,9 "most disease outbreaks reported in ambulatory facilities were associated with nonadherence to recommended infection prevention and control procedures," and as such the focus of disease prevention in the outpatient setting should be on environmental modifications and infection control procedures and not refusal to treat the patient.

Setting the Goal

Full childhood immunization should be the goal of providers, but strict insistence may lead to a lack of well-child care and fragmentation of care for ill children. A "slow and soft" approach to vaccination is more likely to result in appropriate medical care oversight and eventually in vaccination.3,5-7 Although not ideal or proven to provide optimal protection, alternative vaccination schedules open the door to vaccination and may lead to full immunization once parent concerns are addressed.1,5,6 Reassuring parents that the provider's primary interest is the health of the child and stating a desire to continue working with them to identify the right vaccination fit for their family is in line with the founding principles of all healthcare disciplines.5-7

Worth the Trouble

Healthy People 2020 identifies vaccines as the most cost-effective clinical preventive service.10 In fact, for each birth cohort that is immunized with the standard schedule, 33,000 lives are saved, 14 million cases of disease are prevented, healthcare costs are reduced by $9.9 billion, and $33.4 billion in indirect costs are saved. The document concludes that "childhood immunization programs provide a very high return on investment."10

Based on evidence-based practice outcomes alone, all providers need to commit to the Healthy People 2020 objective to "reduce, eliminate or maintain elimination of cases of vaccine-preventable diseases" in their patient and community population.10

It's understandable that exasperated healthcare providers confronted with vaccine refusal by parents would wonder whether the time and energy required to do so is worthwhile. The answer is yes, since it ensures healthcare oversight of the child.


1. Marshall GS. Addressing concerns about vaccines. In: The Vaccine Handbook: A Practical Guide for Clinicians. 3rd ed. West Islip, NY: Personal Communications, Inc.; 2010: 191-240.

2. Some common misconception about vaccination and how to respond to them. Centers for Disease Control and Prevention. www.cdc.gov/print.do?url=http://www.cdc.gov/vaccines/vac-gen/

3. Talking with parents about vaccines for infants. Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/hcp/patient-ed/conversations/conv-materials.html

4. Kimmel SR, Wolfe RM. Communicating the benefits and risks of vaccines. J Fam Pract. 2005;54(1 Suppl):S51-S57.

5. Fernbach A. Parental rights and decision making regarding vaccinations: ethical dilemmas for the primary care provider. J Am Acad Nurse Pract. 2011;23(7):336-345.

6. Fredrickson D, et al. Childhood immunization refusal: provider and parent perceptions. Fam Med. 2004;36(6):431-439.

7. Insel K. Treating children whose parents refuse to have them vaccinated. Virtual Mentor. 2012;14(1):17-22.

8. Singer A. Making the case for vaccines: A new model for talking to parents about vaccines. Immunization, Risk Communication Videos. American Academy of Pediatrics. http://www2.aap.org/immunization/pediatricians/riskcommunicationvideos.html 

9. American Academy of Pediatrics Committee on Infectious Disease. Infection prevention and control in pediatric ambulatory settings. Pediatrics. 2007;120(3):650-665.

10. Healthy People 2020 Overview/Objectives. Immunization and Infectious Disease. http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=23  

Judith Gromek is a family nurse practitioner at East Side Pediatrics in Pittsburgh. She has completed a disclosure statement and reports no relationships related to this article.