Communication and Basic Health Counselling Skills to Tackle Vaccine Hesitancy

"The public health goal is actually to stimulate professionals to reflect upon the need to recognize, develop and adapt basic health counselling skills in order to provide adequate information and emotional support to people who show hesitant attitudes towards vaccinations and can be allowed to activate informed and responsible decisions."

Vaccine-hesitant individuals constitute a heterogeneous group of people. Thus, vaccine communication goes beyond performing one-way informative interventions or teaching, but instead involves initiating mutual dialogue and reciprocal exchange among all people involved, despite their different roles and diverse responsibilities. It entails that communication methods and tools have to be adequately aligned with the specific setting and intended groups. Based on categorisation by the European Centre for Disease Prevention and Control (ECDC) that identifies 4 population groups with vaccine deficit (hesitant, unconcerned, active resisters, poorly reached), this article outlines relevant communication and health counselling skills that healthcare professionals can use to create effective relationships with people who can then activate their own resources and choose solutions that are consistent with their needs.

As reported in Table 1, it emerges that the use of basic health counselling skills mainly applies to 3 out of the 4 population categories: hesitant, unconcerned, and poorly reached. In the cases of hesitant and unconcerned people, it is suggested that public health professionals implement the basic techniques for active listening, such as reformulation or investigative skills, as well as that they be prepared for engaging in information discussions. In the case of poorly reached individuals (people not accessing vaccinations because of social exclusion or work/time pressure), vaccine promotion needs to be developed mostly at the community level, concerning the wider institutional and professional network that involves integrated collaboration overall. Regarding the 2 subcategories of active resisters, i.e., "convinced and content" and "committed and missionary", extensive discussions and debate may seldom be productive, or can even be counterproductive, according to the authors. However, healthcare professionals are advised to show openness and a non-judgmental attitude to leave open an avenue for antivaccination activists to have further contact or a re-examination of their position in the future.

Basic health counselling skills consist of:

• knowledge of the counselling scope that does not correspond with giving advice and quick solutions or general information, but relates to a process of facilitation in order to activate personal resources in the individual;
• self-awareness of qualities that can favour or hinder the relationship and of personal communication style;
• knowledge of and capacity to use the relational skills (empathy, self-awareness, active listening) that are fundamental to relationship creation and maintenance;
• knowledge of the counselling process to structure an intervention in phases that entail some fundamental steps (initial greeting, relationship building by active listening, main problem assessment, feasible goal setting, alternative solution proposal, summarising, evaluation, termination or referral, closure, and final greeting); and
• strengthening the capacity of team working and networking.

The authors explain that the relational skills (empathy, self-awareness, active listening) are integral parts of counselling and can be learned and perfected with specific training. For example, to listen actively, a reference methodology articulated in empathic reflecting involves 4 specific communicative techniques:

1. reformulation corresponds with repeating what the other has just said, using the same words or rephrasing in a more concise way by other terms, without adding any other concepts or different content ("This means that you think...");
2. clarification uses the outlining emotions associated with the content communicated, referring to verbal, paraverbal, and non-verbal communication ("From the look on your face, it seems to me that you are worried");
3. investigative skill is the ability to ask, selecting the most appropriate question type according to the specific situation, "open questions" - preferably at the beginning of the conversation because they allow wider answer options, extend and deepen the relationship, and encourage opinion and thought expression (questions starting with "Why" can be perceived as accusatory, and should be preferably avoided); and
4. the use of first-person messages helps to avoid conflicts by distinguishing between the professional's and another person's opinions; this technique serves also to create a non-judgmental and an autonomous decision-making process ("In my opinion...").

In this participatory communication approach, the public sphere is at the centre, and understanding of social and personal issues at the heart of an interactive assessment that revolves around making scientific information useful to citizens. Especially as far as particular groups are concerned, in the case of childhood vaccinations, parents' fears and worries about adverse reaction effects or vaccine safety are often the basis of their hesitancy. The idea is that, if people perceive empathy toward and consideration of their doubts and opinions, they will be in turn more willing to listen and trust.

In addition, the authors argue that health professionals need to be aware of web-based and new media for 2 reasons: on the one hand, knowing the kind of information that flows through the net could be useful to forestall some possible criticism; on the other hand, groups on social networks may constitute valuable tools to keep individuals up to date with advice and to promptly counter false or ambiguous knowledge they could have found on the internet.

In conclusion: "Looking at the big picture as a whole, in fact, in a multistakeholder scenario the position of public health professionals toward individuals or communities is fundamental as per their key advocacy role in being at the helm of the processes, from planning to development, monitoring and evaluation. Such a framework necessarily demands for strategic communication planning, favoured by the integrated participation and collaboration of institutions, services and systems involved at different levels (national, regional and local)."