Vaccine Hesitancy Is Burdening Pediatricians

Shared decision making may not always be a win for vaccine uptake.

By Clara Silvestri

In early January, the US Centers for Disease Control and Prevention made changes to the United States’ childhood vaccination schedule. This updated schedule cut back the amount of recommended routine vaccines. It also introduced a new recommendation for how parents should approach their child’s vaccines in a section included in a fact sheet released by the Department of Health and Human Services (HHS). As of April, this recommendation has been overturned, but its potentially lasting effects on pediatrician visits and vaccine uptake should not be ignored. The section in question reads:

“It is not always possible for public health authorities to clearly define who will benefit from an immunization, who has the relevant risk factors, or who is at risk for exposure. Physicians and parents, who know the child, are then best equipped to decide based on individual characteristics.”

A decision-making process that weighs risks and benefits for each individual child seems like a very reasonable idea. But experts are concerned that this may actually reduce vaccine uptake — and that decreasing vaccination may have actually been the government’s goal. 

The term “shared clinical decision-making” in the context of childhood vaccination refers to the process by which pediatricians and parents come to an individually based, informed decision as to whether or not a child should receive a vaccine. Even parents who express initial hesitancy towards vaccinating their children continue to view their child’s pediatric provider as a trusted source of information, according to a study published in Academic Pediatrics. This study also found that certain persuasion strategies used by pediatricians positively affected vaccine acceptance. If pediatricians are taught how to use these strategies, then vaccine-hesitant parents may become more receptive.

But using these strategies takes time out of a pediatrician’s already busy work schedule, and many quite literally cannot afford to have a long conversation with every parent who wants to talk about vaccines. The time spent speaking with a parent who ultimately refuses a vaccine for their child typically remains uncompensated for the pediatrician. “If a vaccine isn’t administered, the provider can’t bill for any counseling time,” says Dr. Robert Bednarczyk, an epidemiologist at Emory University’s Rollins School of Public Health. “That’s been a huge issue.”

Dr. Amy Middleman, chief of the Division of Academic Pediatrics and Adolescent Medicine at the Rainbow Babies & Children’s Hospital in Ohio, introduces another issue of practicality. “There are many different types of vaccines, including polysaccharide vaccines, live attenuated vaccines, mRNA vaccines. Not all providers are conversant about the details of each and every vaccine because, from a public health perspective, vaccines are incredibly safe and effective and the benefits have always far outweighed the risks. Burgeoning vaccine hesitancy is adding additional time to visits and decreasing time for additional important preventive health strategies.”

Some research suggests that specific aspects of shared decision-making actually do have benefits for reducing vaccine hesitancy in adult patients. Patient decision aids, or information designed to support patients’ engagement in decisions, have been shown in some instances to increase vaccine uptake. There is also evidence that shared decision-making benefits disadvantaged groups more than groups with higher health literacy, education, and socioeconomic status, which could contribute to a reduction in health inequities.

However, shared decision-making can be difficult for providers to implement. Many struggle with figuring out how to ensure that a helpful conversation actually occurs, according to a study in the Journal of the American Medical Informatics Association. “It would be nice to have some information to help providers when they’re having these shared discussions with patients, because even if they understand the vaccines, they may not necessarily know how to translate that information into a digestible conversation,” Middleman says.

A shift towards individualized clinical decisions may also affect the perception and understanding of vaccines. 76 percent of surveyed doctors agreed that shared decision-making for vaccines creates confusion among adult patients when compared to reliance on the doctor’s spoken word without a decision aid, according to a study in the Journal of General Internal Medicine. For parents, this confusion itself could actually end up increasing hesitancy towards vaccines. “With shared clinical decision-making, there’s a little bit of the sense that the vaccine may not be as important or as needed, so it may be deprioritized,” says Bednarczyk.

Middleman also has concerns about recommending shared decision-making on a broad scale. “Shared clinical decision-making was really intended to be a way to determine whether a person who has a relatively low risk of a disease still wants to get a vaccine that would prevent that disease. But when you are talking about a vaccine for a disease that is required to keep the disease in check in the community as well as keep the patient safe, those vaccines are routinely recommended for a reason. [Shared clinical decision-making] for those types of vaccines is really a way to imply that the decision not to vaccinate is equally scientifically sound as the decision to vaccinate.”

Certain research still maintains the importance of strategic, individualized conversations in reducing vaccine hesitancy. Providing vaccine-hesitant parents with fear-based messaging and evidence-based information about vaccines have not been shown to increase vaccine uptake for their children. The use of a presumptive tone, or pediatricians framing vaccination as the default action, has been effective, but some researchers believe that this technique can come across as manipulative or paternalistic to vaccine-hesitant parents. 

Researchers Jeremy Make and Adam Lauver instead studied the use of “invitational rhetoric” as a way of decreasing vaccine hesitancy among parents. Invitational rhetoric encourages parental engagement with the decision-making process while ultimately trusting the parents’ authority on their reality and accepting their decision without judgement.

Make and Lauver found that of the vaccine-hesitant parents whose pediatricians used invitational rhetoric during the shared decision-making process, 37 percent increased vaccine uptake for their children and 86 percent reported either increased or maximum trust in their pediatrician, shown in their study published in Vaccine. The two researchers believe that in the long run, this sense of increased and sustained trust will both positively impact pediatrician wellbeing and increase vaccine uptake among vaccine-hesitant parents.

Many pediatricians in the Vaccine study who engaged in shared decision-making reported feeling tension between public health science and individual communication strategies with vaccine-hesitant parents. They recognized the importance of advocating for high vaccination rates while also understanding that this advocacy itself might alienate some of these parents. 

Epidemiologist Bednarczyk emphasizes the public health side of this tension. “I think that over time, as we see more of this individualized decision-making, I think people are losing that sense of the communal nature of vaccines,” he says. “Yes, a vaccine helps protect you, but it also helps protect other people. The metrics we use to talk about how well a vaccine works are on a population level, but an individual person might say that if they got a flu shot and still ended up getting sick, this vaccine didn’t work. That doesn’t take into consideration the bigger picture of vaccines.”

Researchers such as Make and Lauver who study vaccine-hesitant parents are trying to find the most beneficial way to balance this tension for the end goal of increasing vaccine uptake. “This tension can actually be productive,” says Lauver. “On the one hand, you need to maximize vaccinations. On the other hand, you have to operate from that same prioritization when you communicate. We have to find a way to live in the tension.” 

The major concern surrounding shared decision-making is that applying this model to routine childhood vaccines may weaken the clarity and urgency that have long supported high vaccination rates and low disease rates. Vaccines recommended for children are recommended because the scientific evidence already strongly favors them, making negotiation a worrisome substitute for assertive guidance. 

Yet an increase in parents desiring shared decision-making amid current HHS leadership may reshape how pediatricians must approach childhood vaccines, bringing into question the effectiveness of specific conversation strategies. The challenge will become designing these conversations to move hesitant parents towards vaccination while continuing to advocate for routine vaccine recommendations as the clearest path to protecting children and communities.