How healthcare professionals respond to parents with religious objections to vaccination: a qualitative study

Background In recent years healthcare professionals have faced increasing concerns about the value of childhood vaccination and many find it difficult to deal with parents who object to vaccination. In general, healthcare professionals are advised to listen respectfully to the objections of parents, provide honest information, and attempt to correct any misperceptions regarding vaccination. Religious objections are one of the possible reasons for refusing vaccination. Although religious objections have a long history, little is known about the way healthcare professionals deal with these specific objections. The aim of this study is to gain insight into the responding of healthcare professionals to parents with religious objections to the vaccination of their children. Methods A qualitative interview study was conducted with health care professionals (HCPs) in the Netherlands who had ample experience with religious objections to vaccination. Purposeful sampling was applied in order to include HCPs with different professional and religious backgrounds. Data saturation was reached after 22 interviews, with 7 child health clinic doctors, 5 child health clinic nurses and 10 general practitioners. The interviews were thematically analyzed. Two analysts coded, reviewed, discussed, and refined the coding of the transcripts until consensus was reached. Emerging concepts were assessed using the constant comparative method from grounded theory. Results Three manners of responding to religious objections to vaccination were identified: providing medical information, discussion of the decision-making process, and adoption of an authoritarian stance. All of the HCPs provided the parents with medical information. In addition, some HCPs discussed the decision-making process. They verified how the decision was made and if possible consequences were realized. Sometimes they also discussed religious considerations. Whether the decision-making process was discussed depended on the willingness of the parents to engage in such a discussion and on the religious background, attitudes, and communication skills of the HCPs. Only in cases of tetanus post-exposure-prophylaxis, general practitioners reported adoption of an authoritarian stance. Conclusion Given that the provision of medical information is generally not decisive for parents with religious objections to vaccination, we recommend HCPs to discuss the vaccination decision-making process, rather than to provide them with extra medical information.


Background
Vaccination programs have successfully controlled many infectious diseases. In recent years, however, healthcare professionals (HCPs) have faced increasing concerns about the value of childhood vaccination [1]. Parental decision making with regard to vaccination is complex. Medical, psychological, social, and cultural aspects can play a role [2][3][4]. Moreover, the medical information provided and trust in the HCP can play a role as well [5][6][7].
Although not all HCPs recommend childhood vaccinations according to the national immunization schedule [8,9], most are convinced of the value of vaccination and many find it difficult to deal with parents who object to vaccination.
Religious objections are one of the possible reasons for refusing vaccination. In the Netherlands, an orthodox Protestant minority of about 250,000 members has religious objections to vaccination. Forty percent of them has been found to not be vaccinated at all [10]. Epidemics of polio, measles, rubella, and mumps have broken out among this group and spread to their relatives in Canada [11][12][13][14]. Orthodox Protestant objections to vaccination focus on the necessity of trust in divine providence. On biblical grounds arguments for vaccination are put forward as well: vaccination may be considered as a gift of God to be used in gratitude [15]. Orthodox Protestant churches leave it up to parents to decide to have their children vaccinated or not.
During the polio epidemic of 1978, Veenman and Jansma identified among orthodox Protestants religious objections, family tradition, and fear of possible sideeffects as major reasons for not being vaccinated [16]. More recently, we performed a study on vaccination decision-making among orthodox Protestant parents and found that vaccinating as well as non-vaccinating parents predominantly used religious arguments to justify their decision. If side-effects of vaccination were mentioned, they often had a religious connotation. Nonvaccinating parents who primarily refused vaccination because of interference with divine providence, also mentioned that man is not allowed to cause disease in a by God given healthy body. On the other hand orthodox Protestant parents who broke with tradition and participated in the National Immunization Program (NIP), interpreted side-effects as a sign of God that they had made the wrong choice [17].
In the Netherlands, all children are offered vaccination free of charge via local child health clinics (CHCs) as part of a NIP (see Table 1). CHC staff consists of trained CHC doctors and trained CHC nurses. They also monitor the children's growth and development [18]. During the standard home visit for every newborn baby, the CHC nurse provides the parents with vaccination information and registers whether the child will participate in the NIP or not. If the parents are unsure, the topic is addressed by the CHC doctor during the first consultation at the CHC. Participation in the NIP is on voluntary basis; vaccination coverage is nevertheless high: more than 95% in 2-year olds [19].
General practitioners (GPs) or family physicians are not involved in the NIP. Other medical care, however, primarily involves GPs. People are listed with a GP who provides general medical care and who coordinates access to specialists and hospital care [20]. The GPs conduct an Influenza Immunization Program, focused on adults and children with a medical indication such as chronic heart or lung disease. Like the NIP this Influenza Immunization Program is offered free of charge.
Religious objections to vaccination have a long history, nevertheless little is known about the way HCPs deal with these specific objections. The American Academy of Pediatrics issued a guideline "Responding to parental refusals of immunization of children" which advises to listen respectfully to all objections, provide honest information, and attempt to correct any misperceptions [21]. A Dutch brochure on objections to vaccination advises largely the same [22]. Few papers were published on the actual response of health care professionals to parents with objections to vaccination [23,24]. The objections in these studies concerned vaccine safety and HCPs responded to them by trying to convince the parents of the medical benefits of vaccination. The response of health care professionals to parents with religious objections to vaccination has -to our knowledge-never been studied.
A qualitative study was therefore undertaken to gain insight into the responses of HCPs to parents with these

Study design
Because of the explorative character of our study we chose a qualitative research design using a grounded theory approach [25]. Semi-structured interviews were undertaken with HCPs who had ample experience with orthodox Protestant parents. According to the grounded theory approach, inclusion of participants was continued until data saturation was reached, coding of the data was entirely based on their content, and emerging concepts were assessed for consistency by reviewing previously coded interviews.

Study population
The study population was composed via purposeful sampling. Participants were recruited in villages with large orthodox Protestant populations. The selection of these villages was based on the results of a previous study [26]. HCPs with different professional backgrounds (CHC doctors, CHC nurses and GPs) and different religious backgrounds were approached by the researchers and invited to participate. HCPs who had little or no experience with orthodox Protestants were excluded. Inclusion of participants was continued until data saturation was reached; this was after 22 interviews. We initially approached 6 more HCPs, 5 of them were excluded because they were not seeing orthodox Protestant patients and 1 HCP could not be interviewed due to logistic problems. Thus, in the end, 22 HCPs who all had ample experience with religious objections to vaccination were interviewed: 7 CHC doctors, 5 CHC nurses and 10 GPs. Six of them were members of orthodox Protestant churches. Participant characteristics are summarized in Table 2.

Data collection
Two interviewers (GvIJ and WLMR) visited the HCPs between January 2009 and June 2010 at their practices to interview them with regard to a number of vaccination topics (see Table 3). The topic list was constructed on the basis of an exploratory meeting with key persons from the orthodox Protestant community, the NIP and CHCs who were represented in the advisory committee of the project. The interviews lasted an average of 30 minutes (range 20-45 minutes). Because vaccination is a particularly sensitive subject among orthodox Protestant parents, observation of consultations was not feasible.

Analysis
The interviews were recorded and transcribed verbatim. The transcripts were thematically analyzed using the qualitative software program Atlas.ti 6.0. Two analysts (WvA and WLMR) independently coded the transcripts and subsequently reviewed, discussed, and refined the coding schemes until consensus was reached. All transcripts were coded and discussed by both analysts. Emerging concepts were assessed using the constant comparative method from grounded theory: previously analyzed interviews were reviewed in order to check if their content fitted into the concept [25].

Results
HCPs reported three different manners of responding to religious objections to vaccination: provision of medical information, discussion of the vaccination decisionmaking process, and adoption of an authoritarian stance. These manners of responding are described in greater detail below. The manner of responding which was applied depended on characteristics of the child, the child's parents, and the HCP him/herself. For each manner of responding the determinants are described.

Provision of medical information
All HCPs reported to respond to religious objections to vaccination predominantly with medical information. They stated that the provision of medical information was their most important contribution to vaccination decision-making, nevertheless many of them thought the provision of such information to be not very rewarding.

Respondent 2, CHC doctor
They think measles is not that serious, it's just a childhood disease . But measles can be really serious and I try to explain that, that it may have serious complications. CHC doctors and nurses reported to provide information on the severity of the vaccine preventable diseases, the benefits of vaccination, and its possible side-effects. They said they attempted to correct any misperceptions and offered later vaccination to parents who were in doubt. The extent of the information that was provided was determined by a characteristic of the child: being firstborn or not. When the child was not a firstborn, most CHC doctors and nurses simply asked if the parents still objected to vaccination. Orthodox Protestant families are large, and CHC doctors and nurses reported not wanting to "bother" the parents too much for fear that they would stop coming to the CHCs for monitoring.
The same was found for the GPs offering influenza vaccination. All of the GPs provided patients with medical information about the vaccination. Moreover, the specific risks of influenza for the patient with a particular medical condition were explained. After repeated vaccination refusal, the GPs generally reported stopping discussion with the patients.

Discussion of the decision-making process
In addition to the provision of medical information, the HCPs sometimes discussed the vaccination decisionmaking process itself. That is, the HCPs verified just how the decision not to vaccinate was made and whether or not the possible consequences of nonvaccination were realized. Some HCPs said they also briefly discussed religious considerations, while others suggested the parents to read a booklet on the religious arguments for and against vaccination published by some orthodox Protestant ministers [15]. Still others systematically discussed all religious arguments for and against vaccination.

Respondent 8, CHC nurse
If they are in doubt I'll discuss that. But I cannot advise them in religious matters. I ask them what they want to know and send them some information Whether HCP s discussed the vaccination decisionmaking process or not depended first and foremost upon the willingness of the parents to engage in such a discussion.
In addition, discussion of the decision-making process depended on HCP-related factors: their religious backgrounds, their attitude to religious objections to vaccination and their communication skills, see Table 4.
Especially an orthodox Protestant background, or at least proper knowledge of the orthodox Protestant religion, was reported to be important. The orthodox Protestant GPs reported being consulteda few times a year -by orthodox Protestant parents for advice on whether to have their children vaccinated or not. In these cases, most of the GPs reported systematically discussing both the medical and religious arguments for and against vaccination with the parents.

Respondent 14, GP
I try to find out how they feel about vaccination and why they came to me to talk about it. Apparently they're not sure what to do. They like to hear the arguments for and against, and I know the medical arguments. But I also know the religious arguments and these arguments are discussed as well. In fact, it's more pastoral than medical.
Respondent 16, GP They sometimes ask: "What should I do?" That's difficult, I don't answer such a question. They have to decide themselves. I give them some material, on which they can base their choice. I show them the pros and cons, medically but also religiously. In the Bible there are arguments for and against vaccination, but it's up to them to weigh these arguments.
Respondent 22, GP I try to tell the whole story, objectively. About the smallpox vaccination in the past and modern vaccines today. I also mention that it's important that they can account for their choice. If you don't feel right about it, you should ask yourself if you should continue in that direction or reconsider your choice.
One of the orthodox Protestant GPs even reported using religious considerations to support the final decision making in a dissenting couple.

Respondent 14, GP
If one does and the other doesn't, then I point to their vows; they are married; they promised in the church that the wife would follow the husband.... If they cannot figure things out themselves, then the husband as head of the family should make the decision and the wife follow him on this. This sometimes works.
Although all orthodox Protestant GPs realized that they could set an example, none of them revealed the vaccination status of their own children to their patients. They reported that they always left the final decision on taking part in the NIP up to the parents.
Apart from the religious background of the HCPs, their attitude to religious objections to vaccination seemed to be important. Some of the HCPs lacked affinity with the dilemmas of the orthodox Protestant parents while others tried to understand their' position.
Finally some HCPs reported that they were willing to discuss the vaccination decision-making process but felt they lacked the skills to do so.

Authoritarian stance
The third manner of responding to religious objections to vaccination, described by the HCPs, was to adopt an authoritarian stance and tell the parents what they must do in their child's best interest. In cases of tetanus post-exposure prophylaxis almost all of the GPs reported to use their medical authority to make parents comply with the immunization regimen prescribed for unvaccinated individuals.

Respondent 17, GP
Tetanus is something that you would not wish upon your worst enemy. If your kid should come down with this, you would never forgive yourself. So I say: "The wound will be cleaned and now a shot because you've never been vaccinated and you've got dirt in your system" and that is usually swallowed more or less without a problem.
Respondent 15, GP I try anything I can think up to persuade them. Only once I didn't succeed.
Respondent 16, GP They have to take it. Well, . . . of course they are not obliged to it. But I explain them that the risk is really high in such a situation. And if I advise them to take a shot, they do so. Respondent 19, GP I sometimes say: "If you get any problems, just tell them that the doctor said that you had to take it." The GPs adopted this authoritarian stance only in cases of tetanus post-exposure-prophylaxis. Given that almost all of the GPs in these cases adopted an authoritarian stance, while none of them did so in any other cases, this approach seemed to be completely dependent on the child running a high risk on serious disease.

Discussion
We identified three manners of responding to parents with religious objections to vaccination: the provision of medical information, the discussion of the vaccination decision-making process, and adoption of an authoritarian stance. The manner of responding was shown to depend on characteristics of the child, the willingness of the parents to engage in a discussion of the vaccination decision, and some personal characteristics of the HCPs themselves.
The three manners of responding to religious objections to vaccination resemble to recent models of medical decision making (in the context of the doctorpatient relationship) in which the informative, the shared decision-making, and the paternalistic approaches are distinguished [27][28][29]. There is, however, a major difference: while providing medical information on vaccination fits into the informative approach, and the adoption of an authoritarian stance on tetanus postexposure prophylaxis fits into the paternalistic approach, discussing the vaccination decision-making process cannot be considered as shared decision-making. Shared decision making means that patient's preferences are taken into account in a final decision that is endorsed by both the doctor and the patient. A prerequisite for shared decision making is that the available options be medically equivalent [30]. This is questionable in cases of vaccination and simply untenable in cases of tetanus postexposure prophylaxis where refusal has a high risk of adverse outcome. Thus, the aim of discussing the vaccination decision-making process with parents who refuse vaccination is to help them make a well-considered decision; that is not necessarily a decision endorsed by the HCP.
All HCPs primarily responded by providing medical information and correcting any misconceptions regarding vaccination. They considered the provision of medical information a key competence of HCPs, and their most important contribution to acceptance of vaccination. Orthodox Protestant youngsters, however, are more interested in religious aspects of vaccination than in medical aspects [31]. And orthodox Protestant parents predominantly use religious arguments to justify their decision on vaccination [17]. Therefore the influence of medical information on parents' final decisions is expected to be limited, as was noticed by some HCPs in the present study.
The discussion of the decision-making process required -except from parental willingness to engage in such a discussion-some religious knowledge, a positive attitude towards parents with religious objections to vaccination, and adequate communication skills.
The religious background of HCPs influences their attention to religious considerations in general clinical practice. In a recent study in the USA, older pediatricians with Christian backgrounds paid more attention to religious considerations than younger, non-religious pediatricians [32]. Similarly, GPs with a Protestant background in the Netherlands have been found to pay more attention to religious considerations in their practice than GPs with a Catholic background [33]. While to our knowledge the present study is the first to focus on the influence of religious background on vaccination discussions, our finding that in particular the HCPs with an (orthodox) Protestant background discussed the decision-making process and the religious considerations involved are in line with these studies. Some extra education on religious aspects of vaccination and training in communication skills could for the other HCPs possibly facilitate the discussion of the decision-making process with orthodox Protestant parents, however the effects of such discussions should be evaluated.

Limitations
The data for this study were collected via interviews with HCPs, andby definitionsubjective. However, the findings are in line with the results of previous studies among orthodox Protestants [17,31]. Because of the sensitive character of the subject vaccination among orthodox Protestants, observation of the HCPs during real life consultations was not feasible. In other research the response of HCPs to simulation patients presenting with standardized problem scenarios was observed [20,21]. Although this method seems to be more objective, in these studies the trust between patient and HCP could not be taken into account. We found that orthodox Protestant parents sometimes preferred to consult their orthodox Protestant GPs with doubts about vaccination, instead of the CHC doctors and nurses who provide the vaccinations. This stresses the importance of trust. Perfectly provided medical information is not enough to make orthodox Protestant parents change their minds.
Another possible limitation on the present study is that the gender distribution of the participants was not balanced. All of the CHC doctors and nurses were female and all of the GPs were male. However, 94% of CHC doctors and the vast majority of CHC nurses in the Netherlands are female while only a third of the GPs in the Netherlands are female [34,35]. Our study population is therefore fairly representative. We tried to include female GPs in our study but, when approached, the female GPs referred us to male colleagues as they saw the orthodox Protestant patients. Given that perceived similarity of values between doctor and patient is an important factor in patient satisfaction [36], it is not surprising that orthodox protestant patientswho generally have conservative views with regard to gender roles and expect women to stay at home and care for the children [37] tend to choose a male GP, if possible with their own religious background. The adoption of an authoritarian stance in cases of tetanus post-exposure prophylaxis, which was only seen among the GPs and thus the male participants in this study, could thus be a gender effect. This seems unlikely in light of the extenuating circumstances created by tetanus exposure, however.

Conclusions
In this study, we identified three manners in which HCPs respond to parents with religious objections to vaccination: provision of medical information, discussion of the vaccination decision-making process, and adoption of an authoritarian stance. The choice of approach depends on the medical condition of the child, the willingness of the parents to engage in discussion, and the personal characteristics of the HCPs themselves. Given that for parents with religious objections to vaccination