Communicating with Parents about Vaccination: A Framework for Health Professionals

"A critical factor shaping parental attitudes to vaccination is the parent's interactions with health professionals. An effective interaction can address the concerns of vaccine supportive parents and motivate a hesitant parent towards vaccine acceptance. Poor communication can contribute to rejection of vaccinations or dissatisfaction with care."

This paper proposes a framework to guide health professionals around the world in communicating with parents about vaccination. By focusing on not only what is said but how it is said, the authors attempt to provide an integrated approach going beyond simply the one-way provision of information. The framework is informed by evidence from decision making and communication research and is applicable for use by health professionals in their vaccination discussions, particularly where there might be parental reluctance to vaccinate. It focuses on recommended childhood vaccines but is also applicable to discussions with other groups recommended for vaccination. The overarching goal of the encounter is to promote quality decisions and, ultimately, vaccination.

There were 4 stages in developing the framework: conducting a literature review, classifying parental positions on vaccination, matching strategies to these positions, and assessing their validity with health professionals. Five distinct parental groups were identified from the literature review of papers providing information about a spectrum of attitudes toward vaccination: the "unquestioning acceptor" (30-40%), the "cautious acceptor" (25-35%); the "hesitant" (20-30%); the "late or selective vaccinator" (2-27%); and the "refuser" of all vaccines (<2%). Based on this process, the authors propose categories or "positions" that reflect different parental attitudes and behaviours regarding vaccination and suggest specific communication strategies tailored to each position. It is noted that, in all encounters, health professionals should build rapport, accept questions and concerns, and facilitate valid consent. For the hesitant, late or selective vaccinators, or refusers, strategies should include use of a guiding style and eliciting the parent's own motivations to vaccinate while avoiding excessive persuasion and adversarial debates. It may be necessary to book another appointment or offer attendance at a specialised adverse events clinic. Good information resources should also be used.

The following excerpt from the paper (with footnotes removed by the editor) outlines the communication strategies that are part of the framework in more depth:

"How discussions are addressed
...Health professionals have a responsibility to ensure that parental consent for vaccination is valid. This requires more than simply giving information and is built upon a relationship and interaction...

[T]he trusted health professional is one who: has spent time with the child and parent; listened to, accepted and addressed their concerns; possesses the necessary scientific information; and uses a whole-person approach that is not patronising but treats parents and their children as individuals. Table 3 lists unhelpful and helpful approaches to communication with all parents.

Health professionals' body language ideally indicates that the discussions are important and distractions, such as using computers while talking, are best avoided. They need to speedily establish rapport and clarify parental concerns, avoiding the temptation to minimise or dismiss these ('Oh there's nothing to worry about, vaccination is very safe nowadays'). Instead it is important to fully understand parents' concerns and motivations using open questions and empathic responses. Although health professionals may be reluctant to encourage questions, with practice, targeted questions allow health professionals to tailor their discussions.

Giving information is an integral part of the immunisation encounter. Here, the skills for efficient information provision are useful....Signposting is the skill of clearly indicating to the parent (or patient) the different phases of the consultation. Chunking and checking refers to the provision of information in small chunks followed by checking the person's understanding. This technique contrasts with the common practice of providing much larger amounts of information before checking, which can lead to information overload.

What to include in discussions with parents
...It is recommended that health professionals give information about common but minor side effects, and rare but serious ones. Written materials, web links, or decision aids given prior to, or used during, the consultation can be helpful....These vary widely between countries and clinicians should be familiar with how to locate them.

Risk communication is best tailored to individuals. In general terms outcomes are better understood when they are specified and when their probability is given in numbers (e.g. 1 in 1000) although some may prefer words....Visual representations of probability have also been recommended and are commonly used in decision aids.

Specific information is most helpful when it is timely, consistent, relevant, up to date, and, where available, local. Parents should also be advised about how to manage the common side effects of vaccinations and how to seek help if they have further concerns.

A tailored approach
Evidence from other areas of healthcare practice suggests adapting the principles of motivational interviewing. This is a form of communication that uses a guiding style, rather than a directing style, for discussions where there is ambivalence and resistance to change. Motivational interviewing involves asking questions that clarify an individual's responsiveness to change and elicits their own motivations for change...

...[M]otivational interviewing builds upon the Transtheoretical Model. This is a framework for understanding the process of behaviour change where individuals may pass through five stages: precontemplation, where they are not considering change; contemplation, where they seriously consider change; preparation, where they plan and commit to change; action, where they make a specific behavioural change which if successful, leads to maintenance of that behaviour, the fifth stage.

Accordingly, Table 4 [lists] strategies tailored to the parent's stage...

Tables 5, 6 and 7 give examples of suggested dialogue for unquestioning and cautious acceptors, hesitant, and refusing parents..."

In the discussion section of the paper, the importance of evaluating this framework is highlighted. The authors say that this may involve group or individual training of health professionals who undergo assessment using standardised patients and validated scales that measure quality of communication. To measure effectiveness of the framework against the aims outlined earlier in the paper (satisfaction, self-efficacy, decision quality, and vaccination uptake), a randomised controlled trial delivered at cluster (e.g., practice) or individual level would then establish its effectiveness compared with "usual care".