Qualitative Focus Groups with Stakeholders Identify New Potential Outcomes Related to Vaccination Communication

As part of a larger project to develop a preliminary Core Outcome Set (COS) for vaccination communication, these researchers conducted a qualitative focus group study exploring how parents and health professionals perceive and experience communication encounters and what outcomes are relevant to them.

The impetus for the COS project is the observation that "A range of societal, professional and individual factors may shape beliefs and support or hinder vaccination behaviour, and communication interventions can impact or address many of these factors. However, despite the fact that a communication intervention may have multiple aims or components targeting several different behavioural determinants, its effectiveness is frequently assessed only through its impact on the target behaviour, e.g. receipt of vaccination. Failing to measure appropriate intermediate or process outcomes, such as attitudes towards vaccination or satisfaction with the intervention, makes it difficult to understand how or why a communication intervention works, or where it fails....In addition to being insufficient to explain why an intervention does or does not work, vaccination endpoint outcomes may not be important to everyone involved in a vaccination communication encounter. For example, parents and professionals do not always share the same view about what communication is seeking to achieve, and what makes a communication encounter 'successful' or 'unsuccessful'."

The researchers divided vaccination communication participants into 2 stakeholder groups: (i) 12 parents or caregivers of young children, and (ii) 19 professionals whose work involves vaccination communication, including healthcare providers, researchers, and policymakers. Between July 2015 and May 2016, 3 focus groups were held with parents and 4 with professionals (there were 2 policymaker sessions: one Australian and one international). In facilitating the discussions, the lead author used coloured print-outs with icons representing different types of communication interventions and interview guides tailored for parents or professionals. The discussion prompts included, for example, asking parents to describe a recent or memorable vaccination communication experience, how it made them feel, and whether they thought it "worked" (achieved its aim) or not.

Sharing quotations as illustrative, the researchers articulate 6 themes that describe facets of parents' experiences with vaccination communication, including their preconceptions, decision-making processes, and impressions of the interaction: (i) concerns or fears; (ii) making a choice; (iii) certainty and confidence; (iv) information balance; (v) trust and the messenger; and (vi) the takeaway (Vaccination-related communication encounters themselves may be brief, but the focus group participants indicated that they continue to think about and reflect on these encounters after they have ended. The takeaway, or how the parent feels after a communication experience, can be just as important as the experience itself, and can shape future decisions. Parents described positive encounters as those where they were left feeling like they had been respected, supported, and were in control.)

Again providing quotations, the researchers outline 5 themes from the focus groups with professionals, who discussed their experiences with vaccination communication in terms of their involvement in communication design, delivery, or evaluation (including brainstorming of potential outcomes): (i) designing and selecting communication interventions; (ii) perceptions about what parents experience, want, and need; (iii) perceptions about what makes a good communicator or communication encounter; (iv) challenges in a communication encounter; and (v) evaluation challenges (One participant asked, "Community engagement, community involvement, community participation, what do they all mean?").

In the second analysis stage, the researchers translated the thematic "experiential" data from focus groups into language compatible with the language used in the outcomes research literature, so they could be considered for COS prioritisation (see S3 Appendix). They identified 47 outcomes raised by parents (see Table 2) and 73 outcomes raised by the professionals (see Table 3). They then combined the parent and professional outcomes, removed duplicates, and compared this list of focus group outcomes with the trial outcomes mapped from an earlier literature review (see S4 Appendix). There were 57 distinct outcomes measured in trials, while 91 total outcomes were raised in the focus groups. Of the focus group outcomes, 61 (67%) had not been measured in trials, with most of the new outcomes arising in the areas of attitudes or decision-making. Yet these outcomes were discussed most frequently and are a shared concern of parents and professionals.

For example, the focus group participants raised several outcomes associated with confidence: confidence in their ability to find or judge the quality of information (both parents and providers), confidence in their own knowledge, and provider confidence in their communication skills. The new knowledge outcomes they raised included knowledge about finding relevant information and judging information quality. Several community participation outcomes related to measuring the functionality of a vaccination-related community health organisation were also uniquely contributed by focus group participants.

Why were most outcomes raised in the focus groups not measured in existing vaccination communication trials? Reasons for this include lack of known or validated measurement methods and limitations on the number of outcomes a given trial can assess. However, according to the researchers, lack of awareness on the part of researchers is another key contributor to the relatively narrow range of outcomes generally selected for trial evaluations.

"Based on the outcomes they raised, successful vaccination communication, for parents, impacts how they feel and how they make decisions - but not necessarily what they do. This is supported by the parent themes, which focused on aspects of the experience such as anxiety, choice, trust and feelings during and after communication encounters." (Notably, only 2 outcomes from the parent focus groups were associated with actual vaccination behaviours or practices.) In comparing these and other parent outcomes to those of professionals, the researchers found that the latter "raised many more outcomes associated with knowledge than the parents. This could indicate that some professionals still think and operate according to a deficit model of knowledge, i.e. if parents are educated and informed about vaccination they will change their behaviour....However, several of the knowledge outcomes raised by professionals were focused on provider knowledge levels, which suggests a different and perhaps more nuanced awareness of the importance of provider-parent communication in the parent decision-making process..."

In conclusion, the researchers observe that "Consulting with stakeholders through focus groups allowed us to explore how parents and professionals experienced vaccination communication, identify those aspects of the experience that were important to them, and translate these into outcomes that can be prioritised into a Core Outcome Set and measured in intervention evaluations." They suggest that the outcomes identified in this study can be integrated with additional outcomes from vaccination and health communication research for organisation into a taxonomy, prioritisation into a COS, and assessment in trials.