Understanding Vaccination Communication between Health Workers and Parents: A Tailoring Immunization Programmes (TIP) Qualitative Study in Serbia

"[T]he insights gained have contributed to a more nuanced understanding of vaccine acceptance, demand and hesitancy in Serbia which can inform the current roll-out of new COVID-19 vaccines."

In recent years, coverage for childhood vaccination in Serbia has been suboptimal and fluctuating, most significantly for the measles-mumps-rubella (MMR) vaccine. In response to a measles outbreak from October 2017 to August 2019, Serbian health authorities tightened vaccine-related legislation but failed to sufficiently engage in active communication with parents and the general public. To address this, Serbia embarked on a project drawing on the World Health Organization (WHO) Tailoring Immunization Programmes (TIP) approach. This paper presents one part of this project: a qualitative study with health workers (HWs) (paediatricians and nurses) focusing on their skills and behaviours in communicating with parents about vaccination. The aims were to explore the process of vaccination communication between HWs and parents (accepting, indecisive, delaying, refusing) and to identify barriers and drivers to effective communication.

Using social sciences, ethnographic research techniques, and behavioural insights, TIP offers countries a process through which to design tailored interventions to increase vaccination coverage by: identifying susceptible groups; diagnosing barriers and drivers to positive vaccination behaviours; and segmenting populations according to behavioural determinants. More information on TIP is available at Related Summaries, below, and at the summaries connected therein.

Fourteen in-depth, face-to-face, individual interviews were conducted from June until August 2018 - nine with paediatricians and five with nurses (all women) - in two community health centres (CHCs) in Belgrade municipalities where a significant drop in childhood vaccination rates had occurred. The interviews were followed by observations of 40 HW vaccination consultations with parents at the CHCs.

Key findings:

• Most parents in the observed consultations accepted vaccination for their child during the consultation (38/40 children); no cases of outright vaccine refusal were observed; two parents delayed vaccination. Indeed, most of the observed parents did not ask any questions nor raise any particular worries. They also mostly relied on their paediatrician's decision about vaccination and were ready to take their advice, thereby suggesting trust.
• While nurses focused on administering vaccines, paediatricians assumed an active role in consultations by initiating and guiding conversations, typically adopting an educational communication style. It was the general perception among paediatricians that some of their colleagues also had an authoritative approach when communicating with parents. Communication to a large degree depended on parents' interest, meaning that paediatricians would give additional information on vaccines only if asked. General communication with parents was observed as relaxed, with HWs acting toward children in a warm and friendly way.
• HWs were confident in their skills to communicate and address concerns of accepting and indecisive parents, which mostly revolved around rumours on vaccine safety. HWs' answers suggested that indecisive parents maintained confidence in HWs to relieve their fears, leading them to respond with empathy, understanding, and encouragement.
• When interacting with delaying and refusing parents, HWs sometimes agreed to delay vaccination to maintain relationships, confident that most parents would vaccinate in due course. "The risk of this approach, if used too often, may be that delaying vaccination becomes socially acceptable among HWs and a practice which could have a spill-over effect on parents, who increasingly might view delaying as socially (and medically) acceptable."
• HWs' behaviour in consultations with refusing parents was sometimes affected by parents' distrust in their recommendations about vaccination. They noted parents could sometimes be quarrelsome and hostile. In such cases, some paediatricians would not engage in further interaction, while others would get involved in a vicious cycle of attempts to convince them, without a positive outcome.
• According to HWs' experience, refusing parents mostly asked the following questions: Who could guarantee the vaccine would not harm the child? Why were vaccines imported and not produced by the national manufacturer? Why was vaccination in Serbia mandatory? What did vaccines contain? The questions referencing a socio-political agenda regarding vaccines or vaccination provoked frustration and stress in HWs, as their skills and strategies mostly proved ineffective in implementing vaccination within this group.

Reflecting on the findings, the researchers observe that "the behavior in vaccination communication is shaped by context, role demands placed on participants and their individual characteristics such as knowledge, emotions, motives or expectations, as well as by cultural factors like shared meanings, ideas, beliefs, values and practices. ...Almost all research participants had over 30 years of working experience, and so many were trained and practiced during times with a more top-down approach in public health with an established authority of health professionals and state regulation practices. ...This may clash with the preferences and expectations of modern young families, especially those who value individual empowerment and patient-choice. If so, the authoritative communication style reported by some interview participants may not be conducive for positive vaccination behaviors among parents, and HWs need support in developing new communication skills and approaches in line with the social and political circumstances."

The findings from this study are being used to inform actions to improve vaccine acceptance and demand in Serbia. In addition to adaptation of an international vaccination communication programme for HWs to the Serbian context, the TIP project developed parent vaccination information resources and delivered a new continuing medical education curriculum on vaccination and vaccinology to 81 HWs across Serbia in 2019. Alongside TIP, the national immunisation programme has intensified efforts to engage with HWs through the network of public health institutes, as well as with parents via roundtable events held at CHCs and enhanced vaccination communication in the media.