This article appeared in SELF. Read the full story here.
If you follow any of the conversations about vaccines that are happening all around us—on social media, in state legislatures, in online groups, and elsewhere—you might be under the impression that people fall into one of two camps: pro- or anti-vaccine. But the truth is more complicated.
For starters the vast majority of Americans vaccinate their children. According to a 2017 analysis by the Centers of Disease Control and Prevention (CDC), only 1.3 percent of two-year-olds born in 2015 had not received any of their recommended vaccines. The problem is that that number—1.3 percent—is an increase from .9 percent of two-year-olds born in the year 2011. So the data shows that while people who don’t vaccinate their kids at all is a very small fraction of the total population, their numbers are growing.
The other fact that recent media coverage of vaccine skepticism might have glossed over is that there is a larger number of people who are not dogmatically opposed to vaccinating, but instead can be more accurately described as what the World Health Organization (WHO) calls vaccine-hesitant. Vaccine hesitancy is “the delay in acceptance or refusal of vaccines despite availability of vaccination services.” Parents might be vaccine-hesitant according to the WHO for a variety of reasons, including lack of trust in a vaccine or a provider, not perceiving a need for the vaccine, or not having access to vaccinations in the first place. In other words, it’s not that these people are vehemently opposed to vaccinating. Rather they aren’t fully convinced that vaccines are safe or necessary.
The good news is that research has shown that people can be persuaded to vaccinate their children even when they initially refuse. According to the American Academy of Pediatrics (AAP), in 2006 and 2013 pediatricians reported that they were able to persuade about 30 percent of parents who initially refused vaccinations for their children to vaccinate their kids. Another observational study showed that when doctors continued to engage parents, up to 47 percent accepted vaccines after first refusing them. It’s clear that health-care providers, if equipped and prepared to do so, play an important role in addressing and decreasing vaccine hesitancy.
So what goes into engaging with someone who is vaccine-hesitant? The AAP recommends that pediatricians be aware of and appreciate that vaccine-hesitant parents are a heterogeneous group whose concerns are varied, and that because of this fact, physicians be ready to answer a variety of questions and speak to a number of concerns. The AAP urges physicians to be attentive to parents’ concerns while correcting any misconceptions, and remembering that “many, if not most, vaccine-hesitant parents are not opposed to vaccinating their children; rather, they are seeking guidance about the issues involved, beginning with the complexity of the schedule and the number of vaccines proposed.” For this reason, doctors should take parents’ concerns seriously, address them, and communicate the message that “vaccines are safe and effective and that serious disease can occur if your child and family are not immunized.”
SELF reached out to six doctors and nurses to learn how they embark on these important conversations.
“Number one is, the first thing I do is listen…instead of giving data and statistics, you share your own beliefs — what you did with your own kids.” — Charles D. Goodman, M.D., M.S., F.A.A.P.
When doctors are pushed for time and stressed about dealing with multiple people per day who are skeptical about vaccines, the temptation can be to rattle off a monologue of well-known statistics and data. But Charles D. Goodman, M.D., M.S., F.A.A.P., says that the most important thing to do is listen and practice empathy.
“Number one is, the first thing I do is listen,” he tells SELF. “I want to know why they feel what they feel. What are their experiences, what makes them hesitant to vaccinate? Where’s this coming from? Just let them talk. And then instead of giving data and statistics—because you will get pulled into what’s called a backfire effect, where they will do the opposite—you share your own beliefs, what you did with your own kids.” He also recounts his own deeply disturbing experiences of vaccine-preventable diseases. “I show pictures of what measles looks like and I tell them when I was a resident at the LA County USC Hospital, I saw many cases of measles every single day because it was the middle of an epidemic. I did see kids that were deathly ill from it. And I show them what those kids look like.”
Above all, however frustrating doctors may find their patients’ points of view, they have to avoid alienating them if they want to have a chance of getting through to them. Dr. Goodman cites a quote widely attributed to Dr. Maya Angelou: “People may forget what you said, but they never forget how you made them feel.” He explains, “If you make them feel bad about themselves and you’re telling them their beliefs are wrong—they’re stupid, they don’t make sense, there’s no basis for them scientifically—they’re going to feel bad. And they’re going to walk away and they’re not going to listen to you, they’re not going to heed your advice. And all the time and effort you spent giving them very good scientific data isn’t going to work.”
Unfortunately, because many of their beliefs aren’t grounded in science you can’t get through to everyone. “If the answer is ‘There’s nothing in the whole world that would make me change my mind,’ then probably I’m not going to be able to, it’s not based on evidence,” he acknowledges. “And you may not be able to change everyone’s mind.” But he says it’s worth trying in any case.
“At the beginning I wasn’t so strong in my statements, but as I’ve been practicing longer I do tell them ‘some of these illnesses can actually kill your child — it is not a benign disease.’ ” — Arunima Agarwal, M.D.
One thing that keeps medical providers fighting so strongly to promote vaccines is that their very young patients can’t speak up for themselves. Following the CDC schedule, a child should get as many vaccines in their first 15 months as they do between the ages of 18 months to 18 years. “That’s probably the most difficult part of it because the child isn’t allowed to make that decision, and in the end they’re the ones who suffer for someone else’s decision [not to vaccinate],” Arunima Agarwal, M.D., a pediatric rheumatologist in Ventura, California, tells SELF. “That does make it hard and that also makes us try to approach it in a different way.”
For instance, Dr. Agarwal says, she’s learned to be more direct. “At the beginning I wasn’t so strong in my statements, but as I’ve been practicing longer I do tell them ‘some of these illnesses can actually kill your child—it is not a benign disease. You can get encephalitis, or meningitis; pneumonia in a one-year-old is a serious disease too. And these are things that we need to prevent.’ I would say I am more straightforward now with them about the risks.”
When someone is skeptical of vaccines, she approaches the conversation by finding out where they are getting their information from: “The first question I always ask is, ‘What are you worried about and where did you get your information?’ If they’re able to answer those questions, they’re probably vaccine-hesitant, where you can sort of talk through it.” In Dr. Agarwal’s experience, people who are committed to never vaccinating, on the other hand, tend to avoid answering or give vague responses. “But for both families I give them information from either the CDC or the American Academy of Pediatrics (AAP),” she says. “Unfortunately there aren’t many that I feel like I can change their mind. But you give them the information and tell them, ‘You can come any time if you want to get the vaccine.’ ”
She admits that watching parents refuse to vaccinate can wear her down. “Yeah, I’d be lying if I said it didn’t,” Dr. Agarwal says, “but at the end of the day it’s for the baby. My priority is the child.”
“If it looks like a patient is really sick but is getting better, usually that’s the time I approach the families with things we could do to prevent this from happening again in the future.” — Allison Messina, M.D.
As chairman of the Division of Infectious Disease at Johns Hopkins All Children’s Hospital, Allison Messina, M.D., usually sees patients at the point at which vaccines are too late because the child is already sick. “Those are really heart-wrenching cases because you know that likely it could have been prevented,” she says. “I have seen children die of pertussis [whooping cough], I’ve seen children die of pneumococcal disease, I have seen kids die of meningococcal disease, and all of those are preventable.”
When she does make a pitch for vaccines, Dr. Messina prefers to lead with questions. “I usually approach it as ‘What are you concerned about, what have you read? What have you read on the internet, what have your friends told you?’ And then we go one by one through the things that they’re worried about. Because sometimes you can talk forever about something they’re not even concerned about, and that’s not worth your time,” she says. Sometimes it’s sharing her commitment to her own children’s vaccines—“Whenever they can get them, as early as they can, my kids are at their doctor’s office getting their vaccines. That’s how strongly I feel about it.”— that can be the deciding factor. “Some parents will ask, ‘Do you give these vaccines to your kids?’ ‘Absolutely. Do you wanna see?’ ” she says.
As you can imagine, it is hard to approach parents whose child is severely ill to point out that a vaccine could have prevented the situation. “Obviously if the patient’s not doing well, or if they have something life-threatening, you don’t want to approach it as if you’re blaming the parent,” Dr. Messina says. “If it looks like a patient is really sick but is getting better, usually that’s the time I approach the families with things we could do to prevent this from happening again in the future or things that we could do to prevent your other children from getting this sick.”
“It is amazing how many people are surprised that there is actually science and evidence to answer their question or that can address their fears.” — Pamela Trout, M.D.
One reason that there’s no definitive response to convince a vaccine-hesitant patient is because they don’t all share the same attitude and concerns. As a pediatrician in Winter Park, Florida, who sees parents who are vaccine-hesitant every day, Pamela Trout, M.D., is familiar with the variety of concerns that parents may have about vaccines, as well as the many different ways they respond to those concerns.
Understanding exactly which kind of concern she’s dealing with can help Dr. Trout tailor her response. “For those that have a specific fear about a vaccine—e.g. aluminum, allergic reactions, overwhelming the immune system—discussing the science is usually helpful,” she tells SELF via email. “It is amazing how many people are surprised that there is actually science and evidence to answer their question or that can address their fears. These are the people I think just need a little nudge to remind them that science is real, and the illnesses we prevent are real.”
In these cases in which the concern comes from an understandable lack of scientific understanding—we’re not all doctors!—the results can be immediate. “Some people change their minds on the spot,” Dr. Trout says. “I find that it depends on what their concern is. If they don’t understand why their child needs a certain shot, often a thorough, non-alarmist explanation about the disease process, and how complications occur, and why certain ages may be at higher risk is all it takes. If they have misconceptions about how the vaccine works, often a good explanation (and maybe a drawing or two) of the shot and the immune process can help them feel more comfortable when vaccinating.”
Unfortunately, it’s often difficult for patients to articulate what it is about vaccination that is making them nervous or scared or skeptical. “[Some people] cannot define why they are hesitant. They just say, ‘I don’t know, but I don’t want it.’ At this point unless you know the patient well and know their motivators, chances are you will not win them over during that visit,” Dr. Trout says. She then has to decide whether or not to keep bringing up the shot at subsequent visits, which can damage her relationship with the patient. “The hardest part about addressing vaccine hesitancy is that it is a very emotional subject. Even the most objective of conversations can quickly go bad if it hits a chord with the patient that makes it personal.”
“I feel a lot of them have been misled by anti-vaccine websites and organizations. So my heart feels for them and I have a lot of sympathy, and I try to provide lots of patience and empathy when I’m interacting with them.” —Melody Anne Butler, R.N., B.S.N., C.I.C.
Melody Anne Butler, R.N., B.S.N., C.I.C., was already a registered nurse when her own up-close and personal encounter with the vaccine education gap persuaded her to commit her life and career to educating others about them. In 2009 she had googled that year’s flu vaccine and became convinced it wasn’t safe. She tells SELF she went back to work and announced she wasn’t getting the shot because she was pregnant and scared. But when her nurse educator heard her say that, she pulled Butler aside and asked her where she had read the information that was scaring her so much. When Butler showed the nurse educator the websites she had visited, the nurse educator walked her through the talking points and debunked each one.
Since then Butler has become an infection preventionist and even founded a nonprofit called Nurses Who Vaccinate (NWV) to help advocate for vaccines in the U.S. and around the world. “Even though I am a vaccine expert, I don’t have all the answers to every single question,” she says. “However, I’ll know someone who does and I’ll do my best to get that information to you.” As a nurse, Butler values the power of knowledge and education. “That is the opportunity for so many things in our world today. I never want to deny someone the opportunity to get information or knowledge.”
Seeing how effective anti-vaccine messaging on social media and online websites can be has given Butler more empathy for parents. “You get parents who are just misguided and I feel bad for them because some of them are just looking for answers…And I feel a lot of them have been misled by these anti-vaccine websites and organizations. So my heart feels for them and I have a lot of sympathy, and I try to provide lots of patience and empathy when I’m interacting with them.”
“You get your point across by driving home how important it is, and you almost have to go for the heartstrings when it comes to something as emotional as this.” — Joanna Bisgrove, M.D.
In situations when explaining the science to people doesn’t work, some physicians try another strategy. “Sometimes […] you go for the emotions,” says Joanna Bisgrove, M.D., who advocates for vaccines on a local level as a family medicine doctor and the school district medical advisor for her hometown of Oregon, Wisconsin, and on a national level as a member of the American Academy of Family Physicians (AAFP). “You get your point across by driving home how important it is, and you almost have to go for the heartstrings when it comes to something as emotional as this.”
And unfortunately there’s plenty of material to provoke an emotional response. Dr. Bisgrove points to the winter of 2017 to 2018 in particular, which was one of the most dangerous flu seasons in recent years. According to CDC reporting, 186 children died from the flu and around 80 percent of them had not been vaccinated. Aside from the swine flu outbreak of 2009 to 2010, that’s the highest number of pediatric influenza deaths seen during a season since the CDC started keeping track in 2004. The CDC’s research also showed that the vaccine was actually more effective for children than adults: It was 68 percent effective for children aged six months to eight years, compared to a 33 percent effectiveness rate for people aged 18 to 49.
Since desperate times call for desperate measures, Dr. Bisgrove incorporated this heartbreaking story into her case for vaccinating. ‘I said last year they found that even though the flu vaccine wasn’t perfect in a lot of cases, they found that it was a lot more effective for children compared to adults, number one; and number two, most of the children who died did not have a vaccine.’ And suddenly I had a lot of parents vaccinating their kids.”
This story is part of a larger package called Vaccines Save Lives. You can find the rest of the package here.