Tips for Better Communication With Vaccine-Hesitant Parents

by Lauren LeBano

Pediatricians are understandably concerned when parents question the necessity of vaccines, request alternative schedules, or outright refuse to vaccinate their child. The development of vaccines was one of the most significant health triumphs of the twentieth century, and quite possibly of human history. Safe and effective immunizations have saved millions of children from death and illness caused by infectious diseases.

Yet despite the undeniable scientific evidence attesting to the safety and efficacy of immunizations, vaccine hesitancy among parents is an increasing problem, with 87% of pediatricians reporting an encounter with a parent who refused a vaccine in 2013, compared with 74% of pediatricians in 2006.1,2

During these encounters, pediatricians regularly engage with vaccine-hesitant parents and strive to change their views on vaccination. “It’s frustrating for pediatricians, but we went into practice to help children stay healthy, and this is part of the ballpark we play in,” said Michael Cater, MD, a pediatrician in private practice in Orange County, California.

Evidence Supports a Presumptive Approach

Vaccines are so important that pediatrician Jesse Hackell, MD, starts by taking a presumptive approach to vaccination, a communication technique that research supports.3 “My presumption is that parents will vaccinate. During the visit, I’ll tell parents which vaccines are indicated today, and I’ll state the reasons for the vaccines and the potential side effects. Then I tell parents that I’m going to have my nurse come in and administer them,” said Dr. Hackell, who practices in Pomona, New York.

Dr. Cater has also taken the presumptive approach at times. In particular, he has anecdotally observed that the presumptive approach has led to an increase in vaccinations for human papillomavirus (HPV) in his practice.

If parents consent to vaccination and have no objections or questions, Dr. Hackell proceeds with vaccination. If the parents object or have questions, then he will answer their questions, present scientific evidence to support vaccination, tell personal stories, or use other techniques to convey the safety, efficacy, and necessity of the recommended vaccines.

Be Compassionate and Willing to Answer Questions

Vaccine-hesitant parents are often a heterogeneous group with different reasons for their positions, but the good news is that many parents will accept vaccination after one-on-one conversations with their child’s pediatrician.3 Dr. Hackell has experience with vaccine hesitancy in his clinical practice, as well as in his role as coauthor of a recent Pediatrics article on the topic.4 “What we know is that if parents are hesitant because they’re confused, then sitting with them, talking with them, and answering their concerns is usually all that it takes,” Dr. Hackell said. “Talking with parents also helps to build a good relationship going forward. You’re showing parents that you’re willing to sit down and answer questions as opposed to being dogmatic.”

Dr. Cater has developed a similar viewpoint over his 40 years of practice in southern California, where vaccine hesitancy is unfortunately common. He advocates talking with parents to understand why they do not want a vaccine, even though the conversation can be time consuming. “You have to be willing to commit the time to convince parents of the need for vaccines, and it may involve several visits,” he said. “You have to be honest, but you also have to develop rapport and be willing to listen to the parents. There’s no substitute for that, and this process takes time.”

Accordingly, Dr. Cater avoids blunt, angry messaging when discussing vaccines with parents. Such an approach is counterproductive and may cause a parent to transfer practices—but not to consent to vaccination. “You have to have an understanding heart,” said Dr. Cater. “You have to take the time to understand specifically what it is the parent is concerned about, because if you understand their concerns, you can address the specific concerns much more effectively.”

Use Available Resources to Explain the Science

Once pediatricians understand a parent’s specific concerns about vaccination, they can answer questions in the office, as well as guide parents to reliable resources. Dr. Hackell’s recent journal article4 offers extensive information on strategies for countering specific questions about vaccines, including the safety and testing process, discredited research on autism and vaccines, and vaccine schedules that deviate from the only evidence-based schedule.

Dr. Hackell’s article also contains guidance on countering the common objection about how “too many vaccines” will “overwhelm the immune system.” Within the article, a table, originally developed by Paul Offit, MD, shows that current vaccines actually use significantly fewer antigens than earlier vaccines. This fact often comes as a surprise to parents.

Providing parents with the chart illustrating antigen use should reassure them that the infant’s immune system is well-equipped to handle immunization. “Immunization is a lot less risky than a trip to the mall,” Dr. Hackell often tells parents.

Drs. Hackell and Cater are both strong advocates of the resources provided by Dr. Offit, a vaccine scientist who directs the Vaccine Education Center at the Children’s Hospital of Philadelphia.5 Among other resources, Dr. Offit’s website provides:

The website is another exceptional resource for vaccine-related information.6 It has an entire section devoted to background information, practical resources, and handouts that address common concerns. Visit the Talking About Vaccines page to download these resources.

Dr. Cater cautions that parents may need to spend some time outside the office with these resources. “Parents may want more time to digest the information,” he said. “My responsibility is to educate, and if I use the right resources and passionately speak to the value of vaccines, at least half of the parents who come in questioning vaccines opt to vaccinate their children by the end of the office visit.”

Personalized Messages Are Persuasive

Although a review of the science supporting vaccination may convince many parents to vaccinate, some individuals will not be swayed by research-based evidence. “The use of science alone is limited in its efficacy,” said Dr. Hackell. “You need to take multiple approaches.” Pediatricians may consider sharing personal stories that illustrate the importance of vaccination and the consequences of foregoing recommended vaccines. “When I went into practice, we lived in fear of having a child enter the office with meningitis or epiglottitis, and I haven’t seen either of these illnesses in more than 30 years,” said Dr. Cater.

When parents question the varicella vaccine despite being presented with scientific evidence, Dr. Cater may choose to share the story and picture of a 6-month-old child he treated for varicella before the vaccine was developed. The child developed a very serious complication of varicella, necrotizing fasciitis, and eventually died from it. “I don’t have any trouble using my computer as a graphic tool,” he said. “I’ll bring parents into my office and show them an image from my teaching file.”

For pediatricians who have been practicing for decades, these stories often come from personal experience with childhood diseases that have only recently been curtailed by vaccines. However, pediatricians who have been trained in the vaccine era may not be able to draw on personal experience with certain diseases. Dr. Hackell wonders if pediatricians will lose the ability to deliver a strong, personalized message as they lose contact with diseases largely prevented by vaccination. “Nonetheless, I think personal experience is a very valid form of communication,” said Dr. Hackell.

In the absence of personal experience, younger pediatricians may draw on their older colleagues’ clinical files and on reports, which catalogues personal examples of children infected with vaccine-preventable diseases.

Pediatricians without a clinical history of treating vaccine-preventable disease may also use current disease outbreaks as a form of personalization. “We all have the ability to react to disease outbreaks throughout the country,” said Dr. Hackell. “The measles outbreak in California, for example, gives us personal experience at a distance. Any pediatrician can pick up the message and say that we don’t want an outbreak to happen here.”

Leading by example is another form of personalization. “You can share that you vaccinate your own children. To me, that’s a very powerful message. I wouldn’t ask a parent to make a decision for their child that I wouldn’t make with equal confidence for my child,” said Dr. Hackell. He also tells parents that everyone who works in his office receives the influenza vaccine in order to protect both themselves and the children they treat.

Messaging and Pediatrician Education

Certain vaccines, especially the influenza and HPV vaccines, are challenging in terms of ensuring widespread dissemination. The HPV vaccine is only mandated for secondary school in 3 states, and the influenza vaccine is only mandated in 3 states for children in childcare,7,8 which means that parents may not view the vaccines as necessities. Dr. Hackell often walks parents through potential scenarios that could occur if parents forego a vaccine for their child. “While influenza is tolerated well by most adults, children die each year because of it. Why take the chance that it could be your child?” and “What would you say to your daughter if she gets cervical cancer at age 35, and you could have prevented it?”

Contributing to the problem, the original marketing messaging for the HPV vaccine was flawed, and the consequences of the rollout may have depressed vaccination rates.9 “It was initially marketed as preventing a sexually transmitted disease, but that’s not its true purpose. It’s a prevention for cancer,” said Dr. Hackell.

Thus, it is important for pediatricians to be up-to-date on both the latest messaging and the science. “You never know what you’re going to be asked,” said Dr. Hackell. “You need to be able to respond to all questions.”

In Dr. Cater’s community, the pediatric residency training program provides extensive training for pediatric residents on how to communicate effectively with vaccine-hesitant parents. Experienced physicians will role-play as parents with vaccination questions, and the residents learn how to give accurate, persuasive responses. After 3 years of such training exercises supervised by infectious disease experts, the residents are well prepared to engage with parents regarding the use of vaccines in their child’s health maintenance program. 

A Reality of Practice

Despite the best efforts of pediatricians, questions about vaccination remain a reality of practice. Most parents are eventually convinced by using the communication techniques outlined above, but there remain rare cases in which parents steadfastly refuse vaccination for their children. In Dr. Hackell’s journal article, the option of dismissing these families from practice is presented for the first time as an option endorsed by the American Academy of Pediatrics when all other avenues have been exhausted, when there are other pediatricians available in the community to provide care, and when the parents have been clearly informed in advance about the practice’s policy. For Dr. Hackell, he can “count on one hand” the amount of times dismissal has been necessary.

Dr. Cater also has experienced very few cases in which dismissal took place. “As pediatricians, we’ve been driven to the wall and sometimes become exasperated, but we have to commit ourselves on a daily basis to keep going forward and doing the best we can,” he said.

Dr. Hackell believes that “if you’re a pediatrician, you can’t get burned out by questions about vaccination. It’s part of the game of being a pediatrician.”


1. Hough-Telford C, Kimberlin DW, Aban I, Hitchcock WP, Almquist J, Kratz R, O’Connor KG. Vaccine delays, refusals, and patient dismissals: a survey of pediatricians. Pediatrics. 2016;138(3). Accessed March 7, 2017.

2. American Academy of Pediatrics; Committee on Community Health Services. Periodic Survey #66: Pediatricians’ Attitudes and Practices Surrounding the Delivery of Immunizations. Published 2016. Accessed March 7, 2017.

3. Opel DJ, Heritage J, Taylor JA, et al. The architecture of provider–parent vaccine discussions at health supervision visits. Pediatrics. 2013;132(6):1037-1046. doi:10.1542/peds.2013-2037.

4. Edwards KM, Hackell JM; Committee on Infectious Diseases; Committee on Practice and Ambulatory Medicine. Countering vaccine hesitancy. Pediatrics. 2016;138(3). pii:e20162146. doi:10.1542/peds.2016-2146.

5.Vaccine Education Center. . Children’s Hospital of Philadelphia website. Accessed March 9, 2017.

6. Immunization Action Coalition. Accessed March 9, 2017.

7. Immunization Action Coalition. State information: HPV mandates for children in secondary schools. Updated February 17, 2017. Accessed March 9, 2017.

8. State information: states with influenza vaccine mandates for childcare. Immunization Action Coalition website. Updated February 17, 2017. Accessed March 9, 2017.

9. Leader AE, Weiner JL, Kelly BJ, Hornik RC, Cappella JN. Effects of information framing on human papillomavirus vaccination. J Womens Health (Larchmt). 2009;18(2):225-233. doi:10.1089/jwh.2007.0711.