Ask any pediatrician and they’ll likely say giving childhood and other vaccines to young patients who might be squirming or scared of needles isn’t easy.
"There’s not one single magic thing that you can do to achieve high vaccination coverage, it’s lots and lots of things combined. Every little bit [of effort] helps."
– Pediatric Infectious Diseases Specialist Sean O’Leary, MD, MPH
Neither is convincing some parents to accept them. Today, doctors often have to face down not only tearful toddlers but parents who are reluctant to give their children one or another recommended vaccine.
Although the uptake of most childhood vaccinations is generally high — around 90% for polio, hepatitis B, chicken pox (varicella), and measles, mumps, and rubella and around 80% for pneumococcal conjugate vaccine and diphtheria, tetanus, and pertussis — several vaccinations provoke some degree of hesitancy. That’s due to everything from complacency to misinformation. This means getting patients over the finish line requires strategy and finesse.
“There’s not one single magic thing that you can do to achieve high vaccination coverage,” says pediatric infectious diseases specialist Sean O’Leary, MD, MPH, a professor of pediatrics at the University of Colorado School of Medicine and Children’s Hospital Colorado who studies barriers to vaccination. “It’s lots and lots of things combined. Every little bit [of effort] helps.”
Childhood immunizations range from a one-time shot to those that are given in a series over the course of years. Here are the vaccines pediatricians say are most likely to meet with resistance, and their tips for how to convince parents it’s the best thing for their child.
HPV
HPV (human papillomavirus) vaccines, which protect against cervical, throat, anal, penile, vaginal, or vulvar cancers, are based on virus-like particles that are formed by components on the surface of the virus. They lack the virus’s DNA, however, so they don’t cause infection. However, they closely resemble the natural virus, so they prompt the body to make antibodies against it.
Possible side effects from the vaccine: Pain, redness, or swelling at the injection site, fever, dizziness, headache, joint pain, and dizziness or fainting.
The concern from parents and guardians: Being vaccinated promotes sexual activity.
When the HPV vaccine was introduced in 2006, it was positioned as a way to prevent a sexually transmitted infection, rather than cervical and other cancers. In fact, the vaccine was shown to be almost 100% effective in preventing cervical, vulvar, and vaginal infections that can lead to cervical and vulvar cancers, and has also been shown to be about 80% effective in reducing the rates of anal and throat infections responsible for those cancers, which are on the rise. The vaccine is most effective when given well before children are usually sexually active (ages 9 to 12), which is unsettling for some parents.
“A lot of parents — and clinicians — just don’t want to go there,” says O’Leary. “There’s often bargaining that goes on in the office like ‘We’ll get two vaccines today and we’ll do one next year.’ And the data shows that if one gets delayed, it’s almost always the HPV vaccine.”
Only 75% of adolescents have received a dose of the vaccine, compared to 89% for the Tdap (tetanus, diphtheria, pertussis) vaccine, for example, O’Leary says.
To encourage vaccination, he advises taking a “presumptive” approach.
“We recommend introducing a vaccine by saying, ‘We have one shot to do today’ as opposed to ‘What do you think about this vaccine?’” he says. “When the pediatrician or family doctor frames it along the lines of this is what we do, it’s the right thing to do, the parent can then be more comfortable in the decision to vaccinate.”
His research shows that using this strategy results in higher rates of HPV vaccination.
When he meets resistance, O’Leary pivots to motivational interviewing.
“It’s a communication technique where you’re trying to create a productive conversation,” he says.
The first step is to elicit parents’ concerns.
“I’ll say, ‘So I understand you’re not interested in this vaccine today. Would you mind telling me why?’” he says.
When parents say they think their son or daughter is too young, O’Leary says, there’s a tendency to start countering with factual information. Instead, he recommends saying, ‘I’ve heard that before and I’ve looked into it. Would you mind if I went over with you why I think it's important to give it at this younger age?’ If they agree, O’Leary explains that the vaccination has been shown to be more effective when given at younger ages, before a patient is exposed to the virus, than in the later teen years.
“We call that question ‘asking permission to share’,” O’Leary says. “It’s not going to work every time. But it's going to make a parent more receptive to what you're then going to say, rather than if you just unloaded on them.”
MMR
“Every single day I see parents who are cautious and concerned about the MMR vaccine.”
– Pediatrician Tisa Johnson-Hooper, MD
The MMR (measles, mumps, rubella) shot is an attenuated (weakened) live virus vaccine, which causes a harmless infection with few or no symptoms. The body develops immunity to the viruses by fighting the infection. (Some children receive the MMRV vaccine, which also protects against chicken pox.)
Possible side effects from the MMR vaccine: A sore arm or rash, swelling of the glands in the neck or cheeks, temporary pain and stiffness in the joints.
The concern from parents and guardians: It causes autism.
This common fear stems from a 1998 study from British researcher Andrew Wakefield, which showed a link between the vaccine and autism. Although the study has been thoroughly debunked by subsequent data, it fueled a persistent misinformation campaign.
“Every single day I see parents who are cautious and concerned about the MMR vaccine,” says pediatrician Tisa Johnson-Hooper, MD, medical director for the Center for Autism and Developmental Disabilities at Henry Ford Health in Detroit and clinical associate professor at Wayne State University School of Medicine.
Her secret weapon in the fight against vaccine misinformation is the trust she builds with families under her care.
“At the very beginning of my relationship with families, I talk about the need to be partners and to make decisions together,” says Johnson-Hooper. “So when we get to these sensitive subjects, there’s trust there. And that goes a long way.”
Johnson-Hooper also takes a presumptive approach to vaccine recommendations and uses the CASE model to communicate with people who are vaccine hesitant. This stands for:
- Corroborate (acknowledge parents’ concerns),
- About me (describe how you built up your knowledge on the subject),
- Science (what the data show), and
- Explain/advise (based on the science, you are recommending the vaccine).
“It’s important to do it respectfully,” Johnson-Hooper adds. “To be seated, looking at patients in the eye, not with a hand on the door.”
Influenza
Recommended each year for everyone six months and older, flu shots are made with either a killed (inactivated) flu virus or with proteins from a flu virus, and are designed to match as closely as possible the strains of influenza expected to be the most prevalent during each flu season. Nasal spray flu vaccine is made with weakened (attenuated) live flu viruses. No type of flu vaccine causes illness.
Possible side effects: The inactivated vaccines may cause mild temporary side effects including reactions at the injection site, fever, fatigue, and muscle pain. The live attenuated nasal spray can nasal congestion, fever, or sore throat.
The concern from parents and guardians: It will actually give me the flu or, simply, I don’t need it.
The uptake for flu vaccine — 67% for children 6 months to 4 years, 58% for those 5 to 12, and less than 50% for those 13 to 17 in the 2021-2022 flu season — generally falls behind other vaccines, O’Leary says.
Some of the lag may be due to inconvenience and simple complacency.
“One of the reasons that we’re not achieving our goals for influenza may be unrelated to hesitancy, but simply parents and their children not visiting the doctor during influenza vaccination season, particularly for older kids and adolescents who don’t go to the doctor that often,” says O’Leary.
The presumptive approach can be helpful when a family is in the office and on the fence, while email and text reminders, particularly for children with risky medical conditions, spur some parents to the doctor or a local pharmacy for the annual shot.
COVID-19
COVID-19 vaccines are mRNA vaccines, which work by delivering the genetic instructions to build the spike protein from the SARS-COV-2 virus’s surface. When the body encounters the virus, it makes antibodies that block cells with the spike protein from infecting healthy cells. Since the actual virus is not used in the vaccine, it can’t cause infection.
Possible side effects: Children ages 3 and younger may have pain where the shot was given, swollen lymph nodes, sleepiness, irritability or crying, or loss of appetite. Children ages 4 to 17 may also experience headache, chills, and muscle or joint pain, according to the Centers for Disease Control and Prevention.
The concern from parents and guardians: It’s not necessary. It’s unsafe. Developed too quickly, it could have negative long-term effects on children.
Fears and misinformation have thwarted COVID-19 vaccination from the moment it became available. When the vaccines were approved for children, anti-vaccine sentiments were already entrenched for many people.
Others just need convincing, says Johnson-Hooper. She starts with the presumptive approach: ‘Good news. We have our COVID-19 vaccine supply and your child is eligible for it today.’
“I'll get parents saying ‘yes’ to everything but COVID-19 vaccines,” says Johnson-Hooper. “And then I’m able to say, ‘What's going on? What are your concerns?’”
When parents are worried about the quick introduction of COVID-19 vaccines, Johnson-Hooper reassures them that the mRNA vaccine research was decades in the making.
“And with each passing month, a year, I can now say hundreds of millions of people have had this vaccine and this is what we know,” she says.
Using the CASE model’s “about me” point, she tells them that her own daughter wanted to get the vaccine the moment she became eligible.
“She wanted to be able to see her grandmother. That was important for her,” says Johnson-Hooper. The tactic often helps.
When parents bring up outlandish claims that they saw on social media, Johnson-Hooper teaches them how to identify credible and vetted websites (generally those with URLs that end in .edu or .gov) and shares information for them to review after the appointment. By keeping the conversation going, she often succeeds in getting shots into arms a month or two later.
“The only way I can do it is through small bites of the apple,” says Johnson-Hooper. “If I stick with the structure and develop that relationship, I can get there.”