When parents won’t vaccinate their children: a qualitative investigation of australian primary care providers’ experiences
Berry et al. BMC Pediatrics
When parents won't vaccinate their children: a qualitative investigation of australian primary care providers' experiences
Nina J. Berry 0
Alexandra Henry 0 2
Margie Danchin 1
Lyndal J. Trevena 0
Harold W. Willaby 0
Julie Leask 0
0 Sydney School of Public Health, University of Sydney , Edward Ford Building A27, Sydney, NSW 2006 , Australia
1 Murdoch Children's Research Institutes, Royal Children's Hospital , 50 Flemington Rd, Parkville 3052, VIC , Australia
2 Lismore Base Hospital , 60 Uralba St, Lismore, NSW 2480 , Australia
Background: Increasingly, the experiences and perceptions of parents who decline vaccination are the subject of investigation. However, the experiences of clinicians who encounter these parents in the course of their work has received little academic attention to date. This study aimed to understand the challenges faced and strategies used when general practitioners and immunising nurses encounter parents who choose not to vaccinate their children. Methods: Primary care providers were recruited from regions identified through the Australian Childhood Immunisation Register (ACIR) as having higher than national average rates of registered objection to childhood vaccination. Interviews began with an exploration of provider experiences with parents who accept, are hesitant towards, and who decline vaccination. Participants were asked specifically about how they addressed any difficulties they encountered in their interactions. Thematic analysis focused on encounters with parents - challenges and strategies. Results: Twenty-six general practitioners (GPs), community and practice nurses (PNs) were interviewed across two regions in NSW, Australia. Providers' sense of professional identity as health advocates and experts became conflicted in their encounters with vaccine objecting parents. Providers were dissatisfied when such consultations resulted in a 'therapeutic roadblock' whereby provider-parent communication came to a standstill. There were mixed views about being asked to sign forms exempting parents from vaccinating their children. These ranged from a belief that completing the forms rewarded parents for non-conformity to seeing it as a positive opportunity for engagement. Three common strategies were employed by providers to navigate through these challenges; 1) to explore and inform, 2) to mobilise clinical rapport and 3) to adopt a general principle to first do no harm to the therapeutic relationship. Conclusions: Many healthcare providers find consultations with vaccine objecting parents challenging and some, particularly more experienced providers, employ successful strategies to address this. Primary care providers, especially those more junior, could benefit from additional communication guidance to better the outcome and increase the efficiency of their interactions with such parents.
Vaccination; Iimmunisation; Communication; Vaccine-hesitance; Consultation; Primary healthcare provider
Primary care professionals encounter a variety of
challenges in their provision of vaccines to children. These
providers must keep up-to-date with increasingly complex
vaccination schedules; manage busy clinic schedules;
assuage distress about injection pain; and address parental
ambivalence about, or even opposition to, vaccination.
While 92% of children living in Australia are fully
vaccinated there is a persistent group, estimated at 3.3%,
who decline completely, select out or delay vaccinations
(vaccine objecting parents). However, these national
figures mask regional variations in vaccination objection
with some regions recording vaccine objection for up to
14% of resident children [3, 15].
Since 1998, parents or caregivers have been required
to demonstrate that their children aged five years or
under are fully vaccinated for age, in order to access
federal government family assistance payments, and in
some jurisdictions, entry to pre-school or kindergarten.
Exemptions to this requirement have been available on
the grounds of medical contraindication or personal
belief. These exemptions were granted if parents provided
a form signed by themselves and a vaccination provider
(usually a General Practitioner or Registered Nurse).
Exemptions on the grounds of personal belief
(including religious beliefs), called “Conscientious Objection”,
required a provider to declare that they had “explained
the benefits and risks associated with vaccination to the
parent or guardian…and informed him/her of the
dangers of not vaccinating”. This category of exemption
was revoked on 31 December 2015.
This qualitative study aimed to explore vaccination
providers’ own accounts of consultations with parents
who decline some or all vaccinations for their children;
the challenges that arise and the strategies providers’
employed to address those challenges. The magnitude of
the challenge presented to vaccination providers by
parents who decline vaccination for their children, is
evidenced by providers’ own observations (admissions) that
these consultations frequently degenerate into adversarial
encounters, even though they are aware that engaging
with parents in this way is almost invariably fruitless .
Nevertheless, primary care providers are known to
influence parents’ decisions about their children’s health
generally , and exert significant influence on parents’
vaccination decisions, both positively and negatively [4–6,
19]. Importantly, parents who have reversed a decision to
decline vaccination for their children identified
‘information or reassurances’ from a health care professional as the
most important driver of this reversal ([14, 23].
The results reported here are a subset of a larger
investigation that also sought providers’ feedback on the
application of the Vaccination Communication Framework .
This study forms part of a multi-study investigation of the
perceived vaccination information and communication
support needs reported by parents and primary health
care providers. The results of this investigation will inform
development of a package of communication and
information resources and strategies designed to assist health
care providers to proactively and positively address
vaccine rejection and hesitancy in primary care.
Study design/ approach
Qualitative in-depth interviews were used to explore the
experiences and practices of childhood immunisation
providers (General Practitioners and Registered Nurses
giving immunisations) working in two regions of NSW
where Conscientious Objection (CO) exemptions to
childhood vaccination are higher than the national average
and full vaccine coverage by one year of age is lower. An
additional two providers, based outside these areas, and
who expressed interest in participating in the research via
social media were also interviewed.
Interviews were structured with reference to parental
positions described by Leask and colleagues 
Although providers’ experiences with parents who accept
vaccination were explored, this paper focuses on their
experiences with the smallest but most challenging
group of parents; those who present as unwilling or not
yet ready to vaccinate their children (Selective/Delaying
or Declining parents). A brief, thematic interview guide
was developed to ensure consistency between
interviewers (Appendix). Ethical approval for the study was
granted by the Human Research Ethics Committee of
the University of Sydney.
Recruitment and sampling
Primary health care providers were recruited to
participate in the research using a mixed recruitment strategy,
which combined purposive sampling (identifying a
population of health care providers likely to encounter
parents who decline vaccination) and intensity
sampling (including respondents with a particular interest
Using the latest available data recorded for the
Australian Childhood Immunisation Register (ACIR), we
identified two local health districts (LHDs) in which very low
vaccine coverage was observed amongst a single quarterly
birth cohort, and in which registered CO exemptions were
higher than the national average of 1.77% . One of the
LHDs was situated in a rural area and the other in an
urban area. Around 83% of children born between the 1st
January and the 31st March 2002 living in these areas
were fully immunised at age two, compared with 92%
nationally. In the rural LHD, CO exemptions had been
recorded for 6.5% of the cohort. However, geographically
defined sub-groups within this LHD were observed to
have recorded exemptions more than four times this
rate. CO exemptions in the urban LHD were lower
(0.9% overall), ranging between 0.6% and 4.4%.
Practices located within these LHDs were identified
and initial contact made by mail addressed to the Practice
Manager (in rural area) or email (in the metropolitan area)
via the list belonging to the primary care region’s
organisational unit, then named a “Medicare Local”.
General Practitioners (GPs), Practice Nurses (PNs) and
Community Nurses (CNs) were invited to contact the
research team if they were interested in participating in
the study. In NSW, 85% immunisations are given by a
nurse or doctor in general practice with 12% by public
community health clinics . In the rural region, a
researcher followed written invitations with face-to-face
contact (visits) to offer further information about the
study. Providers who expressed interest in participating
were then contacted by telephone or email to schedule
Intensity sampling is known to increase access to
interesting and divergent responses, broadening the scope
of the enquiry, providing richer insights than would
otherwise be possible . These cases can also be a
source of thematic triangulation. Mixed recruitment
strategies, combining purposive intensive sampling, have
been used elsewhere [20, 22].
All respondents were interviewed in the initial tranche
of interviews. Initial analysis informed a second, purposive
round of recruitment, to ensure the range of
immunisation provider types were represented. Recruitment ceased
when the research team judged thematic saturation had
Interviews were conducted in two local government
areas between September 2013 and December 2014 in
meeting or consultation rooms at various locations
convenient to participants. Interviews were conducted by
four trained researchers, all of whom had prior
experience conducting research interviews and none of whom
had prior relationships with the respondents. Digital
audio recordings were made and brief supplementary
field notes were taken. To preserve fidelity, the senior
author trained all interviewers, listened to initial
interviews and offered feedback or further instruction as
required. Interviewers moderated their data collection
strategies by listening to a sample of one another’s audio
files, identifying variances, discussing and making minor
modifications to their strategies as required.
Interviewers introduced themselves by describing their
roles at the university and their interest in vaccination
communication research, at recruitment and prior to
commencing the interviews. Each participant was
interviewed only once and interviews lasted approximately
one hour. Participants were offered the opportunity to
check their transcripts but none accepted the invitation.
Digital audio files were uploaded to a secure server,
whereon they were transcribed by a commercial
transcription service and deleted from remote devices.
Analysis followed a grounded theory approach [12, 13].
After the first tranche of interviews, transcripts were
read and re-read with early codes noted (open coding).
Two other researchers independently read a sub-sample
of transcripts selected to capture the variation within the
sample. A coding workshop was convened to discuss
emergent themes and agree on a coding framework.
These early themes informed recruitment of respondents
for the second tranche of interviews. The second tranche
of transcripts was read and the coding scheme was
modified slightly to account for further commonalities
and variations in participant responses. The data were
coded by hand.
In addition, responses given by the two providers who
practice outside the target LHDs, were interrogated.
This strategy aimed generate insight into the question of
whether the accounts given by providers working in
low-coverage communities were typical or reflected
phenomena shaped by the peculiarities of particular,
geographically defined communities.
A total of 26 interviews were completed and analysed.
Seventeen participants were GPs and nine were practice
or community nurses. There were equal numbers of
respondents (n = 13) from the urban and rural LHDs.
Seniority and experience varied widely amongst
respondents. Six respondents had less than three years’
experience. The remainder had been in their roles for at least
three years; some for more than twenty. The majority
of providers (24/26) worked in general practices and
two worked for community health organizations
offering childhood vaccination clinics. All providers who
approached the research group in response to
recruitment activities were interviewed. The responses given
by the two self-recruited providers accorded closely
with those offered by providers working in highly
vaccine resistant communities.
Our primary finding was that a clinical encounter with
a non-vaccinating parent posed significant challenges to
healthcare providers and to the provider-parent
relationship, which they reported using a variety of strategies to
address. In this paper, we explore how declining
vaccination was often viewed as conflicting with providers’
professional identities, sometimes seen to generate a
communication roadblock, which hampered effective
communication with parents and placed the desired
clinical outcome in jeopardy. Thereupon we describe a
variety of communication strategies providers reported
employing to explore and inform parents who decline
vaccination for their children, and note their
commitment to mobilising clinical rapport as a powerful tool
to promote vaccination. Finally, we illustrate providers’
application of the principle, primum non nocere - first,
do no harm – to prioritising and protecting therapeutic
relationships in the service of child health.
Non-vaccinating parents were often perceived as
challenging respondents’ legitimacy as health advocates
and medical experts. Respondents described
experiencing internal conflict, driven by a sense that they were
bound by a set of moral and professional obligations to
the health and wellbeing of the child before them and
to their communities through upholding vaccination
coverage; and that these obligations contained apparent
contradictions that were difficult to resolve. Parents
who decline vaccination for their children were seen to
frustrate practitioners’ capacity to provide appropriate
medical care to that family, while simultaneously
presenting for that medical care. Many respondents
reported feeling very frustrated, even angry, during these
It just really angers me that there are whole populations
of kids here whose kids aren’t protected, because other
parents have been irresponsible (GP4)
Some respondents described experiencing parents’
resistance to vaccinating their children as a direct
challenge to their identities as trusted authority figures.
Some perceived parents’ questioning as casting doubt on
their professional judgment and their integrity. Some
described decling parents as expressing a fundamental
mistrust of established scientific, medical or pharmaceutical
evidence, or saw it as unwillingness on the part of parents
to trust the medical establishment. A few respondents
described declining parents expressing preferential trust in
alternative epistemologies or practitioners, including
traditional, complementary, alternative or ‘natural’ medicine
and peer narratives.
I think there is quite a strong pushback against
medical establishment. So the doctor used to be an
authority figure and the doctor used to be someone
who could not be questioned (GP14)
They’ll go to the naturopath before they come to the
doctor, or they’ll go to the chiropractor before they
come to the doctor. Those people will often tell them
‘don’t get vaccinated,’ and so they’ve heard those things
from people they trust more than the doctor (GP7)
Signing the vaccination objection form
We observed a spectrum of attitudes amongst the
respondents towards signing parents’ exemption forms.
Although none reported refusing to sign the form, some
found doing so presented uncomfortable internal
conflicts between professional duties (to provide appropriate
medical care to the child and family; to protect the
community), their contractual obligations (to the Australian
Government as authorised providers of Medicare
services or to state governments as employees), and their
concern to maintain functional therapeutic relationships
with these parents. These providers felt they had been
co-opted to perform a function that was outside of, or
actually conflicted with, their usual scope of practice.
They felt they had been conscripted to facilitate access
to financial incentives through government legislation,
effectively rewarding parents for failing to comply with
an effective and important public health initiative. These
respondents expressed discomfort with appearing to
condone a parent’s decision to decline vaccination for a
child and therefore place them and others in the
community at risk of infectious diseases.
The issues are in the sense it’s about payment, so
that’s the reason why they’ve come. Why should we
be drafted in to sign a form that’s actually about
payment? Once you’ve got a monetary issue, it’s very
hard to have a conversation about (vaccination). So
why is it fair for doctors to be asked to do that? It is
an ethical dilemma that the government has created
Junior practitioners were particularly conflicted when
trying to balance their obligations to the individual
interest of the family with the risk to the broader
community that non-vaccination posed and the exemption
form represented. Occasionally, a provider felt s/he was
being asked to participate in a policy that offered
parents (financial and social) incentives to decline
vaccination – or at least neutralised disincentives. A few
expressed the view that parents who actively declined
vaccination ought to be denied access to childcare and
tax benefits, articulating a moral connection between
childhood vaccination and entitlement to publicly
funded health and welfare.
If they don’t believe in the system, why should they
benefit from the system? (GP14)
Other respondents saw the form-signing process as an
opportunity to engage with parents’ decision-making
process and address their concerns. In particular, more
experienced practitioners tended to be more comfortable
with process. A few practitioners saw it as formalising a
legal obligation for them to present the risks of
nonvaccination. Others described using it as a tool to
facilitate engagement with a highly hesitant parent. Agreeing
to sign the form was seen as an expression of respect for
the parents’ decision, which then opened the way for
continuing discussion about vaccination. Several GPs
reported using the form as a vehicle for advocacy for their
patients, expressing a belief that non-vaccinated children
should be entitled to the same access to childcare and
tax benefits and as vaccinated children.
I’m happy to sign it, because I think first of all it’s good
to engage with (vaccine refusers) and secondly I don’t
think they should be discriminated against” (GP1).
Most respondents reported feeling frustration during
their encounters with non-vaccinating parents who were
unwilling to engage in discussion. They described these
parents as intractable and felt their efforts to persuade
them to consider vaccinating their children were largely
fruitless. They used emotive language to describe the
parents who object to vaccination (‘difficult’, ‘challenging’,
‘ignorant’, ‘closed’, ‘no common sense’, ‘shut down’,
‘impossible’, ‘resistant’) and their own experiences of
consultations with them (‘hurt’, ‘stressed’, ‘I give up’, ‘waste of
time’, ‘pointless exercise’).
They say ‘I know what you’re going to say, I know
about the science behind it, I’ve read everything, you’re
not going to change my mind, I’m not vaccinating my
Some described finding themselves in a kind of clinical
impasse during these consultations and feeling powerless
to resolve the situation.
Their answer is ‘no not doing that, see you later’ that’s
it. That’s the most difficult, I mean what do you do
with that?’ (GP5)
Some believed that some consultations were so
emotionally charged or laden with potential for conflict
that they risked damaging the therapeutic relationship.
One respondent expressed a desire to avoid the
‘If they’re immunised, I breathe this huge sigh of relief,
because I just don't have to go there’ (GP6)
Most providers felt it was not possible to have an
effective discussion with parents who object to vaccination
within a standard 15-min consultation. Many reported
that their communication skills were compromised on
becoming flustered because they were trying to rush
through the parent’s questions and were conscious of
their obligation to avoid delaying subsequent patients.
To manage these very challenging consultations with
vaccine objecting parents, providers described employing
three common strategies: exploring and informing,
mobilising clinical rapport and protecting the therapeutic
relationship, which was understood to constitute an
application of the long-cherished ethical mandate,
above all do no harm.
Explore and inform
Respondents described attempting to explore parents’
reasons for vaccine objection and then offering credible
information in response. Discussions could be broadly
categorized into; 1) concern-based (i.e. countering a
specific worry, such as whether vaccines are implicated in the
development of autism) 2) risk-based (i.e. whether risk of
contracting a VPD or complication is important, risk of
travelling with a non-vaccinated child) or 3)
knowledgebased (i.e. how the immune system works, benefits of
herd-immunity, the practicalities of non-vaccination with
regards to childcare/school entry and payments).
Many respondents found it helpful to first engage in
enquiry through asking permission to enter the
conversation, open-ended questioning or respectfully
challenging a belief (Table 1). Those who reported successful
interactions with parents described using supportive
language such as ‘dispelling fears’ ‘reassurance’ and
‘alleviating worry’ to describe their approach. These clinicians
reported being vigilant for cues about their patients’
health literacy or receptivity to information, and they
were cautious to avoid overwhelming parents with facts
or scientific research.
You don’t want to cloud the issue. You work out what
your major message is and you make sure that's the
last thing you say. Because if you give them too much
information, the whole brain shuts down (GP16)
However, a few providers described more
confrontational strategies. Some reported dismissing parents’
Well that's rubbish, you do know that?
Table 1 Examples of enquiry described by providers for exploring parental vaccine-objection
Respectfully challenging a belief
Others reported attempting to motivate parents into
accepting vaccination with appeals to fear.
… those parents who I cannot persuade with reason, I
used to give them a video of children choking and
dying of whooping cough, dying of measles, meningitis,
dying of diphtheria. Cemeteries full of kids dying of
And some described reframing parents’ concern for
their children’s wellbeing to incite guilt.
Your little baby who could potentially get a fatal disease
is not protected. How would that make you feel?
Providers commonly referred to government-issued
resources or their local public health units for information
with which to address parents’ concerns. Some described
referring to resources with the parent during
consultation time or send them home with written information.
Less commonly described approaches included
examining each specific vaccine ingredient on the vaccine
information leaflet with the patient. One spoke of inviting a
naturopath into the consultation room to facilitate a
Mobilising clinical rapport
Gaining a parent’s trust was viewed as a crucial tool in
navigating around the communication roadblock.
Providers were keenly aware that building a therapeutic
relationship was the first step in moving a parent towards
immunisation and they employed several strategies
towards this goal.
Rapport is extremely important and I know that when
I get someone who’s got some concerns about
vaccination, if I can’t establish that therapeutic
rapport with them, then it’s going to be difficult (GP5)
Listening respectfully, avoiding judgemental language,
offering more time and being mindful to avoid criticising
or pressuring the parent were commonly referenced
methods to express empathy. Experienced providers
reporting positioning themselves as parents’ allies,
primarily by agreeing to sign the form (meeting the parent’s
perceived need) before attempting to address their concerns.
“Would you mind telling me what in particular you’re worried about?”
“Do you mind if I bring up vaccination at your next visit?”
“How are you feeling …?”
“What would you like to do?”
“That’s interesting, what do you mean by that? ”
I’ll say to them ‘You’re obviously a really great Mum,
you really care about your kids’ — I’ll say something
affirming, something positive to the Mum so you let
them know that you’re on their side – even though I’m
100% ideologically disagreeing with the decisions
they’re making (GP9)
The notion of reciprocity was also important. One GP,
who reported establishing a strong relationship with the
family by supporting the unimmunised child through an
illness, described finding it easier to broach the issue of
vaccination and then to persuade the mother to consider
I think the mother honestly just appreciated that, and
at some [point] we brought up immunisation and she
said ‘well what did you think?’ and I said ‘well I do
think it’s really important’. And it seemed as if from
that, she said ‘right, okay’.(GP6)
Several clinicians reported re-framing vaccination as
being an action consistent with the parent’s strongly held
views. For a parent concerned about vaccination as
‘unnatural’, some reported presenting it as a natural stimulator of
the immune system. Similarly, some respondents
suggested vaccination could be promoted as a socially
conscious act and a unique responsibility of a ‘good parent’.
When it was clear parents would not vaccinate, some
providers reported building rapport by offering selective or
delayed vaccination as an alternative to the full schedule.
This was seen as an opportunity to validate the parent’s
concern while minimising harm. In some cases, the offer
of selective or delayed vaccination was seen to serve as a
‘foot in the door’ – an initial transfer of decision-making
power that opened the way for acceptance of other
vaccinations, perhaps through demystifying the experience
I start off and say ‘look … you don’t have to vaccinate
for like that specific vaccination, you can vaccinate
around it’. It’s classic - they start vaccinating with one,
and then they end up saying ‘look just do it all’. And
you end up doing everything (GP2)
However, a few were very protective of the schedule,
unwilling to deviate from it, either because it was not
possible (many of the vaccines on the NIP are only
available as multivalent vaccines), logistically difficult
(requiring many more presentations to a clinic or surgery), or
because it presented an unacceptable compromise.
They just wanted to pick and mix and you know, we're
just going, "Uh really? It's just what you're asking for is
too difficult, it's too complicated, it doesn't exist, it's
not possible (RN2)
Several providers advocated offering an amended
schedule, but admitted experiencing difficulty with this. They
felt that they needed more information or that the process
increased their workloads.
First, do no harm
Ultimately, most respondents expressed the view that
maintaining a positive provider-parent relationship is
more important to the health of their patients than
achieving vaccination. Providers generally prioritised
keeping the parent engaged with healthcare, and in some
cases this concern drove them to sign Vaccine Objector
Forms. Some noted that maintaining a positive
relationship in the short-term was essential in re-introducing
the vaccination at a later date.
I’m reading a lot of the time ‘will you come back and
see me or do you just feel bashed? – because I’ve got to
create a relationship of some sort so that they’ll still
keep coming back. And not just about the immunisation
conversation, but about anything (GP6)
Respondents even described standing down from their
pursuit of vaccination if they felt the therapeutic
relationship was at risk. This was seen most frequently
amongst more senior providers who appeared more
comfortable with vaccine objector parents and less
inclined to conflate persisting vaccine objection with
professional failure. Some providers spoke of changing
their goals for a consultation once they had accepted
So then- then you move into the harm minimisation
strategy. So firstly, don’t lose the patient because I
think if you become this obnoxious person, "well I'm
not going to look after your child if you don’t
immunise them", or, "you're a bloody idiot, you know,
go and get a life", all you do is you lose the patient
and you lose the opportunity to be of some use and
some value (GP14)
We found that nurses reported less involvement with
vaccine objecting parents, either because consultations
with these parents did not reach the vaccinating nurse,
or because objecting parents rarely present to nurse-led
This study found that most GPs and immunising nurses
found discussions with parents who decline to vaccinate
their children to be challenging. They felt that these
parents cast doubt on their personal and professional
integrity, their authority as medical experts and their
competence as communicators. These encounters also
stimulated strong internal dissonance; many providers
felt their professional obligations (to the child and the
community) conflicted with the primarily bureaucratic
function of exempting parents from complying with the
recommended immunisation schedule. Some seemed to
resent being called upon to sign the exemption form at
all. Some providers managed this dissonance with
These results are consistent with previous research in
Australia and in other countries [17, 20]. One third of
American physicians surveyed in 2009 viewed parents’
disagreement with their recommendations as a lack of
respect for their medical judgement and experience.
Even so, fewer than half of them (15% of respondents)
refused to treat children whose parents chose not to
vaccinate them . A later survey found 40% of physicians
agreed that requests from parents to ‘space out’
children’s vaccinations reduced their job satisfaction .
In adapting to the challenges presented by parents
who decline vaccines, some providers reported
developing a variety of response patterns. In our study most
reported prioritising the therapeutic relationship even in
the face of their misgivings about engaging in the
exemption process. They believed that doing so would
secure future opportunities for engagement and minimise
the potential for harm to the child. Sometimes this
involved offering an alternative vaccination schedule.
Although some respondents expressed an unwillingness
to consider diverging from the immunisation schedule.
The practice of prioritising the therapeutic relationship
and maintaining parents’ trust is consistent with advice
from professional bodies including the Royal Australasian
College of Physicians and the American Academy of
Pediatrics, which recommends against refusing to treat
the children of parents who will not vaccinate their
children [8, 18].
The use of engaged exploration to identify parents’
concerns and address them is also consistent with
current evidence indicating that parents who are highly
hesitant about vaccinating are seeking more balanced
information (rather than promotional material) about
vaccination that address their specific concerns .
While more senior clinicians were more at ease in their
encounters with declining parents and more confident
in their responses, it is likely they would benefit from
opportunities to periodically review and reflect on the
effectiveness of their interactions with this group of
parents in order to expand their suite of
The policy and historical context to this study is
relevant. The study occurred during a time of intense
national debate about immunisation policy and vaccine
objector provisions in Australia at a time when a major
newspaper was actively campaigning to remove
exemption from childhood vaccination on the grounds of
conscientious objection in federal and state legislation
. Some opinion leaders in the medical media
vocally objected to the form signing process and this
joined a generalised chorus of public outrage about
parents who choose not to vaccinate their children
leading to bipartisan support for an amendment to the
Some of our respondents appeared to resent being
asked to sign parents’ CO forms, viewing this as a civic
or bureaucratic function that lay outside their roles as
medical professionals; a function that threatened their
professional independence and conflicted with their
professional obligations to the child and the community.
Historically, the medical professions in Australia have
been uncomfortable with performing any task that could
be or become civil conscription, which is held to be a
direct threat to their professional autonomy, and
therefore their capacity to act in the interests of their patients.
(: 20-23) This position mirrors the principle of the
Separation of Powers, which protects the Judiciary (legal
professionals) from government interference and has
been enshrined in the Constitution of Australia since
1946, when a referendum passed an amendment
prohibiting any civil conscription of doctors. Thus, the
discomfort expressed by our respondents may reflect a
concern that their professional autonomy is under threat
from a government policy requiring them to perform an
action that may be construed by parents as condoning
their decision to decline vaccination for their children.
In November 2015, the Parliament of Australia
eliminated the provision for exemption to the requirement
that children be fully vaccinated in order for their
parents to be eligible for certain financial benefits. While
some state governments may continue to require parents
who decline vaccination for their children to formally
register their objection in order to access childcare, most
providers will receive fewer requests from parents to
sign their exemption forms. In its place will be new
pressure on GPs to provide a medical exemption for
previously vaccine objecting parents or to establish complex
catch up arrangements in order to comply with federal
and state requirements. Hence, the challenge of dealing
with parents who choose not to vaccinate their children
will remain and most likely intensify for Australian
primary care providers. Additionally, our study may provide
insights for jurisdictions that continue to require a
clinician to sign a personal belief exemption as still occurs
in some US states.
This study was limited to 26 healthcare providers, with a
higher proportion of GPs compared to nurses participating
(17 GPs vs 9 nurses). This may have under-represented
the views of nurses. However, as we have suggested,
GPs are more likely to have the primary encounter with
vaccine-objecting parents. Whilst many providers
expressed difficulty with the form signing process, this
requirement will be minimised in future interactions as
only medical exemption forms will be required to
access financial benefits, as both philosophical and
religious beliefs will no longer be valid. This study explores
providers’ accounts of their behaviour during
consultations with parents who decline vaccination for their
children. It does not measure or report actual behaviour;
neither is it concerned with doing so.
We have identified several common challenges
encountered by immunising GPs and nurses during
consultations with parents who decline some or all vaccinations.
The providers we interviewed were often conflicted
about being required to sign Vaccine Objector Forms.
Some perceived this task as threatening their efforts to
maintain fidelity to their professional obligations to the
child and to the community. Some perceived it as a
threat to their fidelity to the health of their patient (the
child) and the community and a few perceived it as an
opportunity to engage parents in a conversation. In
Australia and other countries, jurisdictions may involve
vaccination providers in bureaucratic processes designed
to inform parents or discourage parents from choosing
not to vaccinate their children. Although it is often
suggested that providers need access to educational
materials that address common misunderstandings about the
risks and benefits of childhood vaccination, this study
suggests that providers also need communication
strategies. Such strategies enable them to engender trust and
protect therapeutic relationships with parents who decline
vaccination. Many experienced providers reported
developing these strategies in-situ. Others are likely to welcome
further guidance, particularly more junior professionals
with less experience in vaccination.
Any system that mandates the interaction of
vaccinedeclining parents with providers (such as for government
payments or school entry) should provide support for
those providers. This support may take the form of
legal or professional advice; checklists or discussion
guides; and/ or decision tools designed to support
parents’ decision processes by helping them to consider
the implications of their decision in a systematic way.
Adequate training in conflict management and
specialised communication techniques appropriate to
situations of non-adherence should also be made available
to vaccination providers.
Understanding providers’ accounts of their own
responses to parents who decline vaccination for their
children has provided important insights into their
communication support needs. Further research will investigate
parents’ information and communication needs. Together,
these data will inform the development of a suite of
communication tools that will be refined and tested.
1. We would like to hear about the experiences and
challenges you face when talking to parents
about vaccination. We’re particularly interested
in hearing about your experiences with parents
who are hesitant/have concerns re; vaccination.
2. We’ve chosen your clinic because we’ve identified
your postcode through ACIR as having higher
than average levels of conscientious objection
3. We know that HCPs are one of the most influential
factors affecting a parents decision to vaccinate
or not, so we’d like to talk to GPs and PNs like
you who regularly communicate with parents
Perceptions and challenges
– I’d like to know about the parents who you
encounter and their attitudes to vaccination.
Could you describe a ‘typical parent’ who you
might see, and their attitudes towards vaccination?
– Experiences with;
○ Acceptors.... typical processes, resources, how
do gain consent
○ Hesitant….what do you say? Resources used?
○ Refusers…how do they come to the conversation,
CO form procedures, feelings raised.
– What do you wish you had to make the
The role of vaccination in the community and public health
Perceptions of vaccination in region – rates are
acceptable or problem
Strategies to achieve consultation goals
Communication challenges and perceived needs
Challenges and perceived needs in meeting
Specific resources used when consulting with
parents on vaccination decisions
Could you describe the process (and any resources
or checklists) you use to agree/obtain consent.
“The National Centre for Immunisation Research and
Surveillance has developed an evidence-based set of
guidelines to assist HCPs to communicate effectively with
parents about the benefits and risks of vaccination to aid
in their decision making. As you’re probably aware, when
it comes to immunisation not all parents fit the same
mould, so these guidelines are tailored to the parent’s
attitudes on immunisation to enable the most effective and
efficient transfer of information. The aim of having this
framework is to have an easy-to-understand tool that
can be tailored to your patient and used easily within
the standard consultation time. We hope you gain initial
feedback on the prototype so we can modify it to make it
as helpful as possible”
Reactions to Vaccination Communication Framework
(Show framework materials)
Availability of data and materials
Ethical approval for the conduct of this study was granted subject to the
condition that, “All aspects of the study including results will be strictly
confidential and only the researchers will have access to information on
participants, except as required by law.” Therefore, the dataset supporting
the conclusions of this article will only be made available upon request, and
subject to approval from the Human Research Ethics Committee of the
University of Sydney.
The authors declare that they have each made substantial contribution to
the conception and design of the study; acquisition, analysis and interpretation
of the data; and/or drafting the manuscript. The authors approve of the version
submitted for peer review and accept responsibility for its content. The authors
agree to be accountable for all aspects of the work and to ensure that
questions related to the accuracy or integrity of any part of the work are
appropriately investigated and resolved.
Consent for publication
All respondents consented to participate in this research and to have the
data they contributed submitted for peer review and publication.
Ethics approval and consent to participate
Ethical approval for the conduct of this study (Project No. 2013/428) was
granted by the Human Research Ethics Committee of the University of Sydney.
The conditions of this approval included informing potential participants of the
risks, benefits and expections associated with taking part in the study, and
securing formal consent prior to data collection.
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