The Persuadable Middle—A Target for Increasing Routine Childhood Vaccine Confidence Among Parents in North Carolina

National childhood vaccination rates in the United States have declined in recent years, a trend exacerbated by the COVID-19 pandemic and linked to the resurgence of vaccine-preventable diseases. At the state level, North Carolina maintains strong baseline coverage but increasing numbers of religious exemptions and provisionally enrolled or non-compliant primary and secondary school students points to emerging vulnerabilities in the state's immunization framework.Against this backdrop, this study investigates how parental vaccine confidence, provider practices, and policy environments intersect to influence childhood immunization in North Carolina. It examines how parental beliefs and behaviors correspond-or conflict-with provider experiences, and how provider adaptability, school mandates, and message framing can be aligned to build confidence and improve vaccination uptake.Drawing on a statewide survey of 753 parents and a focus group of 176 immunization providers, this study identifies a "persuadable middle" of parents who are motivated by child protection, open to vaccination, but remain uncertain. Findings reveal that trust, transparent communication, and respectful engagement are essential for fostering confidence, especially when parents value both autonomy and provider guidance.The study proposes a framework for strengthening vaccine uptake by aligning provider communication with parental expectations, emphasizing shared goals, and viewing mandates as opportunities for engagement. Findings support the development of trust-based, relationship-driven strategies designed to reach and motivate persuadable parents.