A Nursing Approach to the Largest Measles Outbreak in Recent U.S. History

Lessons Learned Battling Homegrown Vaccine Hesitancy

Blima Marcus, DNP, RN, ANP-BC, OCN


Online J Issues Nurs. 2020;25(2) 

In This Article

Tips to Address Vaccine Hesitancy

Our experiences have given us lessons to share. This section offers some recommendations about what we have found that works, and also what did not work.

What Works

Visual Aids. Our experience has strongly corroborated that the 2-hour communication training session and the use of fact sheets were the most useful intervention components when talking to vaccine hesitant parents (Dempsey et al., 2018). For example, in this recently published study (Dempsey et al., 2018) on HPV vaccine uptake, healthcare providers were randomized into intervention groups (which included a 5-component healthcare professional HPV vaccine communication intervention) or to control groups to determine effective methods for increasing HPV vaccine uptake. All of the intervention groups reported significantly increased HPV vaccine uptake. Our first parent workshop used a slideshow presentation for this content, but as we discussed different studies and evidence, the women requested to see the studies in person. Having been told frequently that "studies have been done" they reported wanting to see the paperwork. Having learned this, we then began bringing dozens of printed studies to our workshops, allowing the women to review them.

Normalize Vaccination. There are some recommended evidence-based methods to engage with vaccine hesitant parents. Normalizing vaccination as the default is one way to firmly endorse the right approach and has been shown to impact how parents respond. One study examined different ways in which providers communicated with vaccine hesitant parents (Opel et al., 2013). Some engaged in presumptive methodology ("We have to do some shots today") while other providers used a participatory method ("Are you comfortable giving some shots today?"). Presumptive initiation formats with vaccine hesitant parents were associated with significantly increased odds of parental agreement (89% versus 30%) when compared to participatory communication methods. Also, when providers remained firm in their recommendations despite parental resistance, nearly half of the resistant parents (47%) accepted the vaccine recommendations (Opel et al., 2013).

Empower Parents. We have found that parents report increased trust and confidence in their providers when they are given methods to do their own research. We include tips about how to do research and how to evaluate information in our magazine, during our workshops, at health fairs, and we incorporate these tips into our email and phone interactions with the parents (see Table 1). We empower parents to insist on good quality research and teach them how to analyze information critically, skills that most untrained people lack.

Communication Tips. Empathy during an emotional discussion, such as vaccinations, helps patients feel comfortable and safe to discuss their concerns. Listening and validating patients' stories and experiences are techniques familiar to practicing nurses, and they are important when speaking to worried parents with concerns about vaccine safety. In conversations after our provider workshops ended, we learned methods which providers had found useful.

One pediatrician shared that he only raises vaccination during sick visits, since vaccine-hesitant parents are less likely to want to vaccinate their children during illness. This way the parent may feel less pressure to agree to vaccinate and will be able to participate in the discussion more fully. Second, he recommends sitting with the patient and maintaining eye contact. Finally, he has found that if the atmosphere becomes tense, he stops the conversation and offers to continue speaking with the parent another time when both parties are calm (M. Kirschenbaum, personal communication, July 30, 2019).

What Does not Work

Due to widespread mistrust of various medical entities, including suspicion of the Centers for Disease Control and Prevention (CDC), using CDC information is rarely useful in interactions with vaccine hesitant parents. One study examined several methods aimed at improving vaccine uptake. Some parents were given CDC information on the lack of evidence between vaccines and the development of autism. Others were given textual information on the diseases prevented by the MMR, while a third group were presented with images of children who had diseases prevented by the MMR. The final group was presented with dramatic narratives of children who died or almost died of a vaccine preventable illness (Nyhan, Reifler, Richey, & Freed, 2014). None of these methods worked to increase vaccine compliance. In fact, the group given CDC information related to vaccines and autism demonstrated decreased intent to vaccinate after their interactions with the provider. Therefore, we recommend using original sources and data when speaking to parents, and avoiding handouts, visual aids, or data retrieved from governmental health agencies.

Future Work for EMES

Our initiative has several future goals. First, we have begun incorporating outcomes measurements to evaluate if educational interventions are effective to improve knowledge regarding vaccine efficacy and safety; reduce misperceptions passed around the Orthodox Jewish communities in New York, and increase vaccination. One option for these evaluations includes the use of pre- and post-test surveys administered during workshops to evaluate knowledge deficits, or reduction in fears associated with vaccines.

Next, we plan to bring our information to our Orthodox Jewish community via podcasts or audio methods such as dial-in telephone conferences, which are accessible to a community without widespread internet access. We recognize that people have different preferences for learning, and audio methods are convenient for women who can listen while multitasking.

Additionally, we believe that buy-in from childbirth instructors will be a valuable resource for women in this community. By training doulas and instructors and help them become ambassadors for immunizations, we can encourage them to become trusted resources for their clients. Fourth, we plan to continue to provide education to healthcare providers via in-person workshops, webinars, and conferences. We have applied for and received approval for continuing education credits. Topics for continued education include best immunization practices for pregnant women; government policy and vaccination; sexuality and vaccinations; communication tips; and medical exemption guidelines.