As outbreaks of measles continue across the country, public health leaders are doubling down on the importance of childhood vaccination.
But since doctors already know the science behind vaccine safety and effectiveness, researchers are focusing on the best ways to talk about vaccines to wary parents.
On a recent day at Amherst Pediatrics, only three children were due for shots, and all the moms accepted them gratefully.
But the same could not be said for all the children.
One four-year-old due for her Hepatitis A and B shots began to scream as the nurse came in with the syringe, and her mother had to hold her down on the exam table.
This type of vaccine resistance is relatively simple for providers to handle.
“Let’s put your Band-Aids on and you are all done,” the nurse said kindly. “Now you can go home!”
Much harder is resistance by parents, especially in western Massachusetts, which has higher than average rates of vaccine refusal.
At Amherst Pediatrics, the exam rooms and waiting areas are covered in posters about the importance of vaccines.
Still, pediatrician John Snyder said he has to convince at least one parent a week.
“Most parents are either reluctant, hesitant, or unsure about vaccines — not because of some strongly held belief or feeling,” he said. “It's more they have heard so much in the public sphere.”
The modern movement against vaccines took hold in the late 1990s, after a now-debunked study claimed there could be a connection between vaccines and autism. The current scientific consensus is that all common childhood vaccines are safe, but providers don't always know how to make that case to patient families.
“The science of how we convince people to be confident about vaccines is in a very early stage right now,” said Devon Greyson, a professor of communications at UMass Amherst, who studies what works — and doesn't — in convincing families to vaccinate.
Greyson’s research shows doctors have the most success when they simply announce it's time for shots, but don't invite discussion. It's called the emphatic, or presumptive, approach.
Amherst doctor Jennifer Roche has found that to be true.
“I try not to go into a lot of the controversy,” Roche said. “I come out with a very strong statement and say, ‘This is your child's 11-year visit. At their 11-year visit, they need these three vaccines. And this is what it's protecting for.’ And I leave it at that.”
But sometimes a parent pushes back with questions. In those cases, Roche calmly explains what the popular myths get wrong, from the false connection with autism to the belief that too many vaccines at once overload the immune system.
“It's great when the family will say what they've heard or what they're concerned about,” she said, “because it's often very easy to dismantle that.”
Roche has also learned not to talk about side effects, because parents often fixate on the scariest ones, even if they are extremely rare.
Many doctors tailor their approach to each family and where they fall on the vaccine-comfort spectrum.
Experts estimate that two to five percent of parents in the U.S. are vehemently against vaccines – and not likely to budge.
“There's nothing you can do for those people, it's literally a waste of time,” said doctor John Snyder.
Much more common, he said, “are the ones that have some more significant concerns about vaccines but they aren't firmly held beliefs.”
Leora Brown is in that group. She’s one of the few vaccine-skeptics I found willing to talk publicly about their decision-making. (And she happens to be my sister.)
Brown gave birth to twins about three years ago in Virginia. When it came time for vaccines, she and her husband had heard the stories.
“One friend thought that her child got autism [from a vaccine], and I know that's supposedly been disproven since then, but it made us want to do a little bit more research,” she said.
But she said her pediatrician did not want to engage in a debate.
“They did give us pamphlets about all the vaccines,” she said. “It didn't give us any of the arguments about the pros and cons. It just said basically the pros of doing the vaccines.”
At this point, Brown said, she was somewhat frustrated — wanting more of a conversation with her doctor.
For those conversations to go well, Greyson said doctors should start with the assumption that every parent wants what’s best for their child; they just need the right information.
Even Greyson herself was once vaccine-hesitant. Her own child was born just after the infamous autism-vaccine study came out in 1998.
“One of the most prestigious medical journals in the world had published a very small study — which turns out to be terrible, unethical, and fraudulent. But at the time, when it was newly published, that hadn't come to light yet,” she said. “So that gave me the perspective that not all hesitancy about vaccines is irrational.”
Greyson today is strongly pro-vaccine, but her research has found that shaming people for their vaccination views only makes them more entrenched.
Instead she recommends doctors tell personal anecdotes, either about giving their own children vaccines, or about bad cases of vaccine-preventable diseases.
To Greyson's surprise, what rarely works are social media campaigns, such as public health efforts to place pro-vaccine messages in people's Facebook feeds.
“I don't understand why that is, but sometimes just raising a topic that people are fearful about can, it appears, make them more fearful about it,” Greyson said.
Easthampton mom Kate Banigan-White is generally in favor of vaccines, but she was wary of the HPV vaccine, which was offered to her daughter at the age of 11. It protects against some sexually transmitted diseases, including those that can lead to cervical cancer.
Since the vaccine was new at that point, Banigan-White wanted to wait until her daughter was older. So she declined her doctor's advice.
“He respected my decision, but he didn't seem happy about it,” she said.
Banigan-White said with all the previous vaccines, her doctor had been more emphatic and straightforward. But in this case, he asked if she was willing, and offered a conversation.
She's not sure if that influenced her decision to hold off on the HPV vaccine, which she did allow her daughter to get a few years later.
“I don't think I would have made a different decision if it was posed as: ‘OK. Here's what we're doing,’” she said. “Honestly, that's a good question. I don't know.”
There’s also controversy over whether doctors should decline to treat families who refuse vaccines, which can function as a type of persuasion.
That’s what happened to Leora Brown.
“They said: you know, either you do it, or you need to find another practice,” she said.
Frankly, it worked. She reluctantly agreed to the vaccines because she didn't want to switch doctors. In retrospect, she's glad it worked out that way.
“Considering that I don't feel like they have had any negative effects from the vaccines, I'm very grateful now that they don't have any of any serious diseases or the risk of it,” she said.
But many doctors are against this hardline approach.
Doctor Pam Rockwell, a vaccine advisor for the Centers for Disease Control and Prevention, considers it unethical. But she does insist unvaccinated children use a separate back door at her pediatric practice in Michigan.
"For some, that might be a shameful thing, if they interpret it that way," she said. "But it's me protecting my other patients. [Those refusing vaccines] need to know that they're putting others at risk."
Jennifer Roche, the Amherst pediatrician, never turns away anti-vaccine families — partly because as she builds trust, they sometimes change their minds. And even when those parents remain steadfast in their beliefs, the children are always in the room listening.
“We have had several patients that have turned 18, have not been fully vaccinated and have come in and chosen to begin vaccines,” Roche said.
As of late June 2019, the CDC has reported about 1,100 cases of measles — the most since the disease was declared eliminated almost 20 years ago.
And for some, that's one of the most persuasive reasons to vaccinate.