When Parents Won't Vaccinate Their Children: A Qualitative Investigation of Australian Primary Care Providers' Experiences

"Although it is often suggested that providers need access to educational materials that address common misunderstandings about the risks and benefits of childhood vaccination, this study suggests that providers also need communication strategies. Such strategies enable them to engender trust and protect therapeutic relationships with parents who decline vaccination."

This study aimed to understand the challenges faced and strategies used when Australian general practitioners (GPs) and immunising nurses (INs) encounter parents who choose not to vaccinate their children. In that country, while 92% of children are fully vaccinated, some regions record vaccine objection for up to 14% of resident children. Research has shown that primary care providers are known to exert significant influence on parents' vaccination decisions, both positively and negatively. In fact, parents who have reversed a decision to decline vaccination for their children identified "information or reassurances" from a health care professional as the main driver of this reversal.

The study occurred during a time of intense national debate about immunisation policy and vaccine objector provisions in Australia. A major newspaper was actively campaigning to remove exemption from childhood vaccination on the grounds of conscientious objection in federal and state legislation. Some opinion leaders in the medical media vocally objected to the form signing process; this joined a generalised chorus of public outrage about parents who choose not to vaccinate their children, leading to bipartisan support for an amendment to the incentives legislation.

Twenty-six primary care providers in New South Wales (NSW) were recruited from regions identified through the Australian Childhood Immunisation Register (ACIR) as having higher than national average rates of registered objection to childhood vaccination. Conducted between September 2013 and December 2014, the interviews began with an exploration of provider experiences with parents who accept, are hesitant towards, and decline vaccination. Participants were asked specifically about how they addressed any difficulties they encountered in their interactions. Thematic analysis focused on encounters with parents.

The interviews revealed that providers' sense of professional identity as health advocates and experts became conflicted in their encounters with vaccine objecting parents. Providers were dissatisfied when such consultations resulted in a "therapeutic roadblock", whereby provider-parent communication came to a standstill. Many respondents reported feeling very frustrated, even angry, during these encounters. Most felt that it was not possible to have an effective discussion with parents who object to vaccination within a standard 15-minute consultation. There were mixed views about being asked to sign forms exempting parents from vaccinating their children. On one side, there was a belief that completing the forms rewarded parents for non-conformity; put more strongly, the discomfort expressed by some respondents may reflect a concern that their professional autonomy is under threat from a government policy requiring them to perform an action that may be construed by parents as condoning their decision to decline vaccination for their children. On the other hand, some respondents see the presentation of the form during the clinical encounter as a positive opportunity for engagement (for continuing discussion about vaccination).

Three common strategies were employed by providers to navigate through the challenges presented by these conversations:

1. Explore and inform - Discussions could be broadly categorised into: (i) concern-based (i.e., countering a specific worry, such as whether vaccines are implicated in the development of autism); (ii) risk-based (i.e., whether risk of contracting a vaccine-preventable disease (VPD) or complication is important); or (iii) knowledge-based (i.e., how the immune system works). Many respondents found it helpful to first engage in enquiry by asking permission to enter the conversation, initiating open-ended questioning, respectfully challenging a belief. Those who reported successful interactions with parents described using supportive language such as "dispelling fears", "giving reassurance", and "alleviating worry" to describe their approach. These clinicians reported being vigilant for cues about their patients' health literacy or receptivity to information, and they were cautious to avoid overwhelming parents with facts or scientific research. Providers commonly referred to government-issued resources or their local public health units for information with which to address parents’ concerns. Some described referring to resources with the parent during consultation time or send them home with written information.
2. Mobilise clinical rapport - Listening respectfully, avoiding judgemental language, offering more time, and being mindful to avoid criticising or pressuring the parent were commonly referenced methods to express empathy. Experienced providers reporting positioning themselves as parents' allies, primarily by agreeing to sign the exemption form (meeting the parents' perceived need) before attempting to address their concerns. Several clinicians reported re-framing vaccination as being an action consistent with the parent's strongly held views. For a parent concerned about vaccination as "unnatural", some reported presenting it as a natural stimulator of the immune system. Similarly, some respondents suggested vaccination could be promoted as a socially conscious act and a unique responsibility of a "good parent".
3. Adopt a general principle to first do no harm to the therapeutic relationship - Ultimately, most respondents expressed the view that maintaining a positive provider-parent relationship is more important to the health of their patients than achieving vaccination. Some noted that maintaining a positive relationship in the short-term was essential in re-introducing the vaccination at a later date. The practice of prioritising the therapeutic relationship and maintaining parents’ trust is consistent with advice from professional bodies including the Royal Australasian College of Physicians and the American Academy of Pediatrics, which recommends against refusing to treat the children of parents who will not vaccinate their children.

In November 2015, the Parliament of Australia eliminated the provision for exemption to the requirement that children be fully vaccinated in order for their parents to be eligible for certain financial benefits. While most providers will receive fewer requests from parents to sign their exemption forms, in its place will be new pressure on GPs to provide a medical exemption for previously vaccine objecting parents or to establish complex catch up arrangements in order to comply with federal and state requirements. Hence, the challenge of dealing with parents who choose not to vaccinate their children will remain and most likely intensify for Australian primary care providers.

This study forms part of a multi-study investigation of the perceived vaccination information and communication support needs reported by parents and primary health care providers. The results of this investigation will inform development of a package of communication and information resources and strategies designed to assist health care providers to proactively and positively address vaccine rejection and hesitancy in primary care. This may support one conclusion of the present study: "Primary care providers, especially those more junior, could benefit from additional communication guidance to better the outcome and increase the efficiency of their interactions with such parents." This support may take the form of: "legal or professional advice; checklists or discussion guides; and/or decision tools designed to support parents’ decision processes by helping them to consider the implications of their decision in a systematic way. Adequate training in conflict management and specialised communication techniques appropriate to situations of non-adherence should also be made available to vaccination providers."