Fighting Vaccine Hesitancy, One Parent at a Time

Programs aim to counter anti-vaccine sentiments with parent-to-parent connections.


This story was originally published on Oct. 25, 2019 in NYT Parenting.

In the Spring of 2014, Nadine Gartner was traveling through Portland International Airport when her phone buzzed with an alarming news alert. The previous day, someone with measles had passed through the same terminal that Gartner — and her 1-year-old daughter — now sat in.

Gartner’s daughter had just been vaccinated, right on schedule. Still, Gartner knew that it takes a week or two for the measles, mumps and rubella vaccine to offer its full protective benefits. She spent the next few weeks racked with nerves, checking her daughter for symptoms: hacking cough, fever and those telltale Koplik’s spots, red with bluish centers, which thankfully never arrived.

That experience was life-changing. A year later, Gartner had gone part time at her law firm job to start Boost Oregon, one of the few independent, parent-led nonprofits dedicated to “community-based, grass-roots education” about vaccines. Today, Boost Oregon remains parent-led and funded by individual donations or small community health grants. Gartner said Boost does not accept money from pharmaceutical companies, groups that are the definition of untrustworthy in anti-vaccine circles.

[Vaccine laws are changing. Here’s what you need to know.]

Despite the best efforts of the public health establishment, American parents are still increasingly wary of vaccinations — to great consequence. When a measles scare hit Disneyland recently, officials were spurred to issue a warning that hundreds had possibly been exposed to the highly infectious illness. Add the infected theme park visitor to the 1,250 cases recorded so far in 2019, including a monthslong outbreak in New York City.

Yet, even as the outbreaks continue, anti-vaccine propaganda seems to get only scarier — and more effective. The question is: What will help parents sift through the noise?

It is no coincidence that just the week before the Disneyland exposure was widely reported, the Centers for Disease Control and Prevention announced that the vaccination exemption rate among American kindergartners rose for the third consecutive year to 2.5 percent for the 2018-2019 school year, up from 2.3 percent the previous year, a sign that vaccine hesitancy isn’t going anywhere.

Most parents do vaccinate, but the effects of even a slight downturn in vaccination rates for highly infectious diseases can result in outbreaks. What’s more, roughly 30 percent of parents are “vaccine hesitant” — meaning they have significant concerns about vaccines and may spread out the timing of vaccinations against medical advice or refuse certain vaccines altogether, said Dr. Robert M. Jacobson, a professor of pediatrics and medical director for the population health science program at the Mayo Clinic Center for the Science of Health Care Delivery. This practice is perceived as a middle road and safe bet by parents, but it’s also risky — particularly if providers or the community don’t nip it in the bud.

Many strategies for alleviating fears have been investigated by researchers. Presuming parents will vaccinate seems to help; as does customizing the information by, say, providing facts debunking the link between vaccines and autism, if that’s what the parent is most concerned about. But these approaches focus on “What do we do if someone leaves the pediatrician’s office without a vaccine?” said Jennifer Reich, a University of Colorado sociologist. It’s just as important to ask: “How do we encourage parents and families to feel invested in each other?” she said.

Reich’s research, compiled in her book “Calling the Shots,” found that vaccine refusal and mistrust is the product of two cultural threads: the rise of individualist parenting and the notion of personal responsibility for disease. “We’ve sold a story in public health that if you count your calories, read labels, whatever it is, you can manage disease through hard work,” Reich said. “These two ideologies have collided in a way that it’s somewhat logical that what we would see is vaccine refusal. And that’s not a failure of parents.”

Gartner had no idea vaccines were controversial until her first pregnancy, when friends began asking if she planned to vaccinate. Many of them — all college educated, upper middle-class Portlanders like herself — weren’t vaccinating. Gartner did some research, and ultimately decided to follow her pediatrician’s advice. “I thought, ‘They’re doing what works for them. I’m doing what makes sense to me,’” she said. “But the airport experience honed in for me that it doesn’t matter if I choose to vaccinate my children and no one else does. Vaccines only work when the community participates together.”

This realization is behind Boost Oregon’s two tenets: Don’t just assume that parents who delay or refuse vaccines are stupid. And don’t ever tell parents what to do.

Through workshops at coffee shops and toy stores, Boost Oregon presents the facts, face-to-face, and answers questions. The organization creates resources for other parents to lead their own workshops or education campaigns at schools. These resources, which are online, haven’t reached the huge audiences anti-vaccine propaganda has. But they have been shared across state lines — parent-to-parent — in Georgia, California and New York.

Gartner’s bet is that her slow and steady approach can turn the tide. An anti-vaccine Facebook post can reach hundreds of thousands of users in the span of a few hours. Undoing the fear that post spreads takes many hours of gentle, nonjudgmental counsel from a parent’s own community. “Fear is a feeling. You can’t answer a feeling with a fact. You have to answer a feeling with a feeling,” Gartner said. “We have to change the culture of immunization from one of fear to one of love.”

Gartner’s organization is small and her success is only anecdotal at this point, but Boost joins other parent-led groups like Colorado Parents for Vaccinated Communities and Vaccinate California, which focus on advocacy as well as education on the community benefits of vaccines. Gartner’s approach falls in line with another research-backed technique called motivational interviewing. M.I. has been used to help people quit smoking or drinking, and early research suggests it’s helpful for improving use of the HPV vaccine among adolescents.

M.I. is now the basis of a Canadian program led by Dr. Danielle Auger of the Quebec Ministry of Health and Social Services to install “vaccination counselors” in every Quebec maternity ward by 2021.

The program is based on the research of Dr. Arnaud Gagneur, a French neonatologist who first tried motivational interviewing on vaccine hesitancy in France. He was moved to action after the tragic death of a baby in his care who hadn’t been vaccinated against meningitis. After positive initial results, he brought the idea with him to Quebec, where he now works.

M.I. is wholly different from the traditional medical approach, which is hierarchical (with the doctor in charge and the patient following orders). In fact, the counselors are not necessarily doctors. “We’ve found that the vaccine knowledge can be learned,” Dr. Auger said. “But what’s more important is the personality of the counselor.”

These counselors, who meet parents during the 24 to 48 hours they are in the maternity ward, do not presume they know what’s best, nor push vaccinations on hesitant parents — their job is to simply talk through parents’ fears and goals, and let them decide what to do.

“As a physician, I’m used to taking a position of the expert. With motivational interviewing, you’re not in a position of being an expert. You meet the person where the person is,” Dr. Auger said. “You also have to be respectful. You don’t give information. You ask: ‘Do you want the information to answer that question?’ A majority of physicians or nurses want to convince a patient. But in doing so, for the people who are hesitant, it makes them more hesitant because they feel pressured.”

Studies done by the Quebec government (which funded the program) found a 15 percent increase in parents’ intention to vaccinate, and that the children of parents who participated in the program were 9 percent more likely to be fully vaccinated at age 2. That success has held steady even as the program has expanded: The most recent data, according to Dr. Auger, shows a 50 percent drop in vaccine hesitancy even in the most resistant parents and increases in vaccination coverage at 2 months (a 2 percent increase), 5 months (5 percent) and 7 months (6 percent).

“That’s very high. We already have 88 percent coverage so to get it to increase by 2 percent, you have to work very hard,” Dr. Auger said.

Dr. Gagneur said in an email that he had applied for grant funding through the European Center for Disease Control and Prevention to test a similar approach at sites in Europe and the United States, but whether installing dedicated vaccination counselors, which is costly and energy intensive, will work in other places remains to be seen.

“It’s not cheap,” Dr. Auger admitted.

A trial to train American doctors to use M.I. during counseling for the infant vaccine series is currently underway, said Dr. Sean O’Leary of the University of Colorado. “Motivational interviewing is really a tool. Essentially what it’s trying to do is make these conversations more effective and so it doesn’t turn into an argument.”

But Dr. O’Leary does not think the Canadian model of installing counselors is feasible within the U.S. health care system. “Who would pay for that?” he said. Instead, training providers — and, yes, engaging parents to help educate others — could be more important here.

The more prevalent vaccine hesitancy becomes, the more important it will be to focus funding on approaches that have proved successful, no matter the resources. So far, what appears to work is skipping the parent-shaming and instead focusing on face-to-face, parent-to-parent interactions that calm fears and encourage parents to think beyond themselves.

[Read our guide to the vaccines you need during pregnancy.]

Amelia Harnish is a freelance journalist who covers health and culture.

Correction, Oct. 28, 2019: An earlier version of this article stated that Boost Oregon does not accept donations from major medical organizations. While Boost is an independent organization, it does accept donations and grants from hospital systems and other reputable medical organizations.